- Email: [email protected]
Using Simulation in Nursing PhD Education: Facilitating Application of Responsible Conduct of Research Principles
USING SIMULATION IN NURSING PHD EDUCATION: FACILITATING APPLICATION OF RESPONSIBLE CONDUCT OF RESEARCH PRINCIPLES MARGARET F. CLAYTON, PHD, APRN⁎, KATHERINE SUPIANO, PHD, LCSW†, REBECCA WILSON, PHD, RN‡, MADELINE LASSCHE, MSN§, AND GWEN LATENDRESSE, PHD, CNM, FACNM† Simulation is a standard clinical nursing educational approach; however, simulation is rarely used in nonclinical nursing education. In doctor of philosophy (PhD) programs, ethical content about responsible conduct of research (RCR) is traditionally didactic, presented early in the program of study. Ethics content merits review before students begin the dissertation phase; thus, the purpose of this project was to design and implement simulated scenarios to help students apply RCR principles prior to beginning independent research. Two scenarios were developed: (a) a potential protocol change discussed in a research team meeting and (b) an in-home data collection experience with an elderly participant and her daughter. Actors were trained faculty volunteers, playing roles outside their usual academic positions. Faculty facilitated scenarios by posing questions as cues related to desired learning outcomes as scenarios unfolded. Eleven nursing PhD students and 6 faculty participated. Debriefing facilitated discussion of RCR principles, common research quandaries, and suggested scenario revisions. Faculty, expert observation, and video-review showed that younger and less experienced students tried to give the “right” answer rather than implement RCR appropriate solutions. Students with more clinical experience had difficulty adopting the less familiar researcher role. Overall, simulation is a novel and useful way to enhance RCR content in PhD programs. (Index words: Responsible conduct of research; Ethics; Simulation; PhD nursing education; Scientific education) J Prof Nurs 0:1–6, 2016. © 2016 Elsevier Inc. All rights reserved.
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ESPONSIBLE CONDUCT OF research (RCR) commonly known as ethics training is an essential
* Associate Professor and Assistant Dean, College of Nursing, University of Utah, Salt Lake City, UT 84124. † Associate Professor and Director, College of Nursing, University of Utah, Salt Lake City, UT 84124. ‡ Assistant Professor (Clinical) and Director, College of Nursing, University of Utah, Salt Lake City, UT 84124. § Assistant Professor (Clinical) and Executive Director, College of Nursing, University of Utah, Salt Lake City, UT 84124. Address correspondence to Dr. Clayton: College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT 84124. E-mail: [email protected] (M.F. Clayton), [email protected] (K. Supiano), [email protected] (R. Wilson), [email protected] (M. Lassche), [email protected] (G. Latendresse) 8755-7223 Journal of Professional Nursing, Vol 0, No. 0 (June), 2016: pp 1–6 © 2016 Elsevier Inc. All rights reserved.
component of graduate scientific education and a critical component of professional behavior (Anderson et al., 2007; Heitman & Bulger, 2005; Peirce & Smith, 2013; Stenick, 2007). However, while simulation has become a standard educational approach to teach clinical nursing skills, little has been done with this approach in nonclinical programs, for example doctor of philosophy (PhD) programs offering scientific educational preparation (Fanning & Gaba, 2007; Horvancsek, 2007). In PhD programs, ethics education is traditionally didactic and is a component of the core curriculum early in a student's course of study. However, when students move forward to the implementation phase of their dissertation, we have found that questions persist or arise regarding application of these principles. Revisiting the application of RCR principles prior to students beginning their independent research may help students navigate unexpected “real life” situations, facilitating 1 http://dx.doi.org/10.1016/j.profnurs.2016.05.010
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presenting more research challenges rather than basic knowledge. This approach to development helped us create scenarios that would assist students to apply their knowledge to potential research quandaries that might occur during the conduct of their independent research. The final step in simulation-based education is to debrief participants. Debriefing and feedback are considered to be the most important phase of experiential learning (Cheng et al., 2014). Facilitated structured debriefing helps learners to reflect on their performance and consider what the experience means in terms of future practice (Decker et al., 2013). Ideally, debriefing occurs in a psychologically safe environment with a skilled facilitator focused on the identified learning outcomes (Decker et al., 2013).
ethical and appropriate solutions to commonly encountered research situations.
Purpose The overarching purpose of this project was to develop, implement, and evaluate two simulated scenarios in PhD education. Scenarios incorporated potential areas of confusion and common questions about RCR previously observed by PhD program faculty during supervision of dissertation research. Facilitating student application of RCR principles prior to conducting their dissertation research has the potential to decrease risk for inadvertent research misconduct.
Simulation Pedagogy Simulation is a common approach to providing active, experiential learning. When designing simulation exercises, it is essential to match the complexity of the scenario and the content of the scenario to learner needs, creating a situation that is challenging but not overwhelming (Jeffries & Rogers, 2007). An education matrix is a novel tool that is useful for calibrating a simulation-based experience. With lesser expertise, basic knowledge is provided. As expertise is attained, the focus on knowledge lessens, shifting to essential and supporting competencies, which also lessen as expertise increases and, finally, to increasingly complex challenges that are presented to the most experienced learner. Figure 1 illustrates the shift from knowledge to competency to challenge and presentation of increasing complexity as learner expertise is attained. Increasing complexity is indicated by more + marks in the table. This approach is based on a task analysis framework that has been used to structure simulation-based training in the U.S. Air Force (Alliger, Beard, Bennett, Colegrove, & Garrity, 2007) and models of skill acquisition (Dreyfus, 2004; Dreyfus & Dreyfus, 1980) (Figure 1). An educational matrix accounts for increments in skill performance based upon experience and education, allowing us to build scenarios that matched our student needs and experience level and evaluate student performance. Because our participants were PhD students who had completed didactic ethics training, we focused on
Methods As a direct result of expressed faculty concerns about retention of ethical content based on supervision of students conducting their dissertation research, a task force of nursing PhD program faculty was formed. Simulation was suggested as one way to help students apply learned ethical principles; thus, simulation faculty and experts joined the task force. After robust discussion of commonly experienced ethical dilemmas, two scenarios were developed. Although this project was educational in nature, we obtained institutional review board (IRB) approval so that we could more widely disseminate findings from this novel approach to scientific ethical education. Another reason for obtaining IRB approval was to role model what we were teaching students. Scenarios were piloted with 11 second and third year nursing PhD students who had not yet begun their dissertation research. The simulation laboratory provided a safe controlled environment where students could apply learned didactic principles of RCR, offering faculty a way to further integrate RCR principles into our PhD program. As is customary in simulation pedagogy, we used videotaped scenario observational data to evaluate student performance in relation to an educational attainment matrix. Grades were not assigned to student participants. To help us appreciate how we might
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Figure 1. Educational Matrix indicating a shift from the provision of basic knowledge to complex challenges as learner expertise increases. 1 1Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.
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evaluate the use of simulation in PhD education and move this project forward, we asked a member of our university's Center for Teaching and Learning Excellence to observe the implementation of scenarios. The observer prepared a formal written report and shared it with PhD program faculty and other faculty participants.
Scenario Development The RCR taskforce met several times to develop scenarios and determine the most appropriate learning objectives for each scenario. High-fidelity simulation using live actors as the scenario leaders and confederates (other scenario participants) was determined to be the most appropriate methodology for simulation delivery to elicit both the cognitive, emotional, and affective components of conducting independent research among PhD students. Two scenarios were developed to enhance the PhD curriculum. Scenario One addressed the addition of an instrument that would enhance study findings, discussed in a research meeting. The scenario ended when the student recognized the need to submit an IRB protocol amendment. Objectives for this scenario included specifically recognizing the need for an IRB amendment when a protocol change is deemed necessary, asserting the need for an IRB amendment while maintaining a collaborative affect with the research team and verbally advocating for the IRB amendment. Students were also given an opportunity to challenge authority and take ownership of their research. Scenario Two simulated an in-home survey data collection experience with an elderly participant and her adult daughter who provided progressively more answers to researcher questions as the elderly participant's fatigue increased. The scenario ended when the student indicated awareness that data obtained from the nonconsented daughter are neither IRB approved nor valid and suggested alternatives such as a second home visit to complete data collection. Objectives for Scenario Two included recognizing family member interference in study participant responses, understanding that the participant is the only person who should answer the survey questions, and intervening using a respectful and collaborative demeanor with the increasingly assertive family member. Facilitation and student guidance during scenarios were provided by faculty actors posing questions as cues related to desired learning outcomes as the scenarios unfolded. After the scenarios were written, a scenario leader and confederate (defined as other actors in the scenario) scripts were created for both scenarios to ensure that all graduate students received the same standardized simulation. Both scenarios were vetted by PhD experts and peer reviewed by four content experts prior to delivery.
Participants Six faculty volunteers served as scenario leaders and scenario confederates. Faculty volunteers were trained in facilitation of their scenarios. Faculty were carefully advised on issues of student confidentiality and the
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nongraded nature of these exercises. To help students to suspend disbelief and participate fully in the scenarios, we cast faculty as actors outside their usual faculty roles. For example our Scenario One “statistician” was portrayed by a gerontologist faculty member, and our elderly research participant directs one of our Doctor of Nursing Practice specialties. All second and third year PhD students were invited to participate. Eleven student participants individually participated in both scenarios (every student experienced both scenarios) representing all students enrolled in their second or third year of coursework. Student participants were all female and 32–53 years of age (mean = 40 years). Two were Bachelor of Science in Nursing-PhD students, 9 were Master of Science in Nursing-PhD students (5 students had Master of Science in Nursing degrees; the other 4 had allied health master’s degrees but were not nurses); 2 of the 11 participants were international students. There were no exclusion criteria. Students were informed that simulation exercises designed to enhance their knowledge of RCR were planned as a special educational event. Informed student consent was obtained for participation and to videotape scenarios for later analysis, scholarly dissemination of findings, and educational purposes. Information about the project was presented to the entire group of students in a single session to allow for a collaborative atmosphere where all participants could ask questions, with the added benefit of all participants hearing the same information and answers to any questions. After all questions were answered, students independently chose to participate or not and were free to leave the simulation laboratory. No students declined participation.
Setting Scenarios were implemented in the clinical simulation center within our college of nursing. A room configured in a conference room style was used to simulate the research team meeting associated with Scenario One. Scenario Two used a “living room” style room to simulate a furnished home environment. These rooms were considered similar to typical conference rooms and household family rooms as a way to optimize the balance between experimental control and ecological validity, in addition to optimizing fidelity in simulation pedagogy. All rooms in the simulation center are outfitted with unobtrusive ceiling-mounted pan–tilt–zoom cameras. All sessions were video recorded by a simulation operations specialist. Simulation operations specialists all completed the Collaborative Institutional Training Initiative (CITI training) and were authorized to participate in human participants' research.
Scenarios in Action The simulation day consisted of an initial group information session, individual consent, simulation scenario prebriefing, simulation activity by participants, flash debriefing, and a final group debriefing. Following consent, all participants were prebriefed regarding the
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simulation experiences using a standardized script. Participants received clipboards, pens, and a copy of the prebrief to review and write notes on prior to the simulation experiences. Questions were answered regarding each simulation experience, and all participants were given a schedule for their “simulation appointment.” This allowed participants to come and go as needed between individual simulation appointments maximizing use of student time and respecting their other commitments. Participants were on their honor not to discuss scenarios with others until the group debriefing had occurred. In addition to the schedule, a “green room” was provided where participants could choose to relax and wait in a quiet area before and after their simulation appointments. Debriefing was scheduled as a group at the end of the simulation day. This allowed participants to gain understanding and learning from peer-to-peer interactions.
Debrief A very brief “flash” debrief was conducted privately with each student immediately upon completion of each scenario to gauge student responses, emotional experiences, and answer immediate questions. It was here that misconceptions were discovered that were then able to be addressed generally (and anonymously) in the more formal group debrief. For example, one student commented in her flash debrief that she would simply disqualify the elderly patient rather than attempt a second data collection appointment. This led to a later group discussion of statistical power and length of recruitment time for a study and the ethical responsibility to participants and participant respect without drawing undue attention to the individual student. Another flash debrief student comment mentioned that it was more important to keep going with the study given that submitting an amendment would take “forever,” fostering a later discussion of how an IRB functions and how students can keep abreast of the progress of an amendment. The rationale for and pros and cons of changing a research protocol were also discussed. This comment raised the question of how to handle data from participants who had completed the study prior to an anticipated protocol change and who had not received the new instrument. Other general issues identified in flash debrief and discussed in group debrief included how to manage and educate the adult daughter answering questions for her mother and how forceful a researcher should be versus how polite when interacting with an increasingly insistent family member who is not part of the study. A comprehensive group debriefing was held when all students had completed all scenarios. Our goal was to facilitate student engagement and shared self-reflection in a safe and constructive manner with appropriate faculty feedback and discussion. According to Rudolph, Simon, Rivard, Dufresne, and Raemer (2007), “goals of debriefing include allowing students to explain, analyze, and synthesize information and emotional states to improve future performance in similar situations” (p. 361).
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Despite being a nongraded activity, we anticipated that students would experience some “performance anxiety” as they engaged in the simulations. We proceeded in the group debrief with the assumption that our students were motivated to learn RCR and become capable researchers and that faculty would respectfully share honest, rigorous feedback in a nonjudgmental manner. The faculty member conducting the debriefing for our PhD students was a trained and licensed PhD-prepared social worker with decades of clinical and research experience handling difficult emotional situations. This background was instrumental in her ability to draw out student feelings of inadequacy and possible reasons for these feelings in group discussion that avoided singling out any particular student, then to shift the discussion to the scenario objectives and reinforce learning points, opportunities, and solutions that encompassed RCR principles. Faculty were also debriefed as a group to discuss their opinion of using simulation of RCR principles to enhance our PhD program and for their experiences as actors. Suggestions for revision and improvement were discussed in both student and faculty group debriefing sessions.
Results Results indicated students were supportive of simulation and that learning had occurred with student misconceptions corrected in a safe learning environment. Six students had extensive prior research experience as part of their employment, three had limited research experience (e.g., as a Research Assistant), and two students had no prior research experience. We observed that students with less research experience and younger students were initially concerned with getting the “right” answer as opposed to developing solutions to posed situations. With actor encouragement and facilitation, all students successfully completed both scenarios. Common RCR principles that students had trouble applying during Scenario One (addition of a new survey instrument) demonstrated that not all students appreciated that a consent form is a contract between the participant and researcher with respect to obligations, benefits, and risks. Students also evidenced some confusion on what behaviors violated informed consent. When faced with excitement from research team members about including the additional instrument, some students did not explicitly realize an IRB protocol amendment would be necessary, although all students mentioned in some fashion that the IRB would need to be involved. During debriefing, it was apparent that students were universally afraid of interactions with the IRB and felt that this would inordinately delay study progress. Discussions helped students to appreciate that the IRB is not “out to get them,” that amendments can be completed in a timely manner, and that amendments are needed when participant obligations change (i.e., the need to complete an additional instrument). Observations from Scenario Two showed that students with more clinical experience had trouble relinquishing
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the familiar clinician role and adopting the less familiar researcher role in the “home” environment when faced with a fatigued participant and a daughter providing participant data. Some students tried very hard to be polite to the participant's family member to the detriment of valid data collection. Students stated in debriefing that they were surprised when guided to a solution of a second home visit by faculty facilitation. They did not realize that the solution was “that easy.” When discussing the solution of a second home visit during debriefing, some students said that they initially felt that they did not want to “bother” the family with a second appointment; however, they recognized the benefit of this approach when respect for the highly fatigued participant and the validity of the data were discussed. In addition, other RCR points were stimulated including a discussion of who might actually fill out a survey in this family if it was mailed instead of administered in person in the home environment. Recommendations for revision and improvement from faculty and students alike were to use paid actors rather than volunteer faculty. Faculty cited the time required to implement scenarios, feeling that this could be decreased. Students discussed the desire to not be seen as less capable when attempting to apply RCR principles in front of faculty they might wish to ask to be on their supervisory committee. Faculty also commented during their debriefing that they were highly supportive of continuing to use simulation as a way to enhance our curriculum and wanted to participate in ideas for development of future scenarios.
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Conclusion Evaluation of student solutions to unfolding scenarios illustrates the need for greater opportunities to apply RCR principles as students prepare to conduct their dissertation research. RCR principles learned in early didactic courses are not uniformly applied when students are presented with “real life” situations during simulation. The simulated high-fidelity environment allowed students to immerse themselves in the potential issues associated with conduction of RCR on emotional and pragmatic levels rather than just intellectually in a theory discussion or case study. Our results indicate that using simulation to practice and reinforce RCR principles helps students' ability to make appropriate decisions and apply ethical principles in a safe and controlled environment. Additional ways that we are reinforcing the application of ethical conduct of research include incorporating guest speakers from the IRB and other departments on a regular basis into scheduled student activities. In summary, the use of RCR simulation exercises to exemplify real-life research dilemmas is one way to enhance preparation of students to conduct their own dissertation research and evidence excellence in the responsible conduct of research. Simulation pedagogy holds great promise for application to the learning of RCR skills for future scientists.
Acknowledgments The authors gratefully acknowledge the assistance of participating faculty and the Center for Teaching and Learning Excellence at the University of Utah.
Discussion
References
Overall, this project grew out of faculty observations that students were not consistently able to apply RCR principles during independent dissertation research. Faculty were frustrated when they discovered that inappropriate solutions had been implemented on the spot, leaving them in a difficult supervisory position. Students were frustrated because they intellectually understood didactic content delivered during their first semester, but they had less knowledge about how to implement solutions to more pragmatic situations that could occur during the dissertation phase of their PhD program. Thus, the idea of using simulation to allow students a safe place to practice and apply RCR-based solutions to common research situations was developed. Faculty voiced the need to “hard wire” redundancy of content in different ways to cement student learning. Carrying this project forward, we have continued the work of our RCR PhD program faculty task force, developed a tool box of resources for faculty supervising students, held regular forums where faculty discuss supervisory issues of students with other faculty to gain ideas on best supervisory practices, and incorporated feedback from both faculty and our Center for Teaching and Learning Excellence expert as we develop a library of scenarios that will be rotated and implemented during the PhD program of study for all students.
Alliger, G. M., Beard, R., Bennett, W., Colegrove, C. M. & Garrity, M. (2007). Understanding mission essential competencies as a workload requirement. AFRL-HE-AZ-TR-2007-0034. Anderson, M. S., Horn, A. S., Risbey, K. R., Ronning, E. A., De Vries, R. & Martinson, B. C. (2007). What do mentoring and training in the responsible conduct of research have to do with scientists' misbehavior? Findings from a National Survey of NIH-funded scientists. Academic Medicine, 82, (9), 853–860, http://dx.doi.org/10.1097/ACM.0b013e31812f764c. Cheng, A., Eppich, W., Grant, V., Sherbino, J., Zendejas, B. & Cook, D. A. (2014). Debriefing for technology-enhanced simulation: A systematic review and meta-analysis. Medical Education, 48, (7), 657–666, http://dx.doi.org/10.1111/medu.12432. Decker, S., Fey, M., Sideras, S., Caballero, S., Rockstraw, L., Boese, T. & Borum, J. C. (2013). Standards of best practice: Simulation standard VI: The debriefing process. Clinical Simulation in Nursing, 9, (s6), S26–S29, http://dx.doi.org/ 10.1016/j.ecns.2013.04.008. Dreyfus, S. (2004). The five-stage model of adult skill acquisition. Bulletin of Science, Technology & Society, 24, (3), 177–181, http://dx.doi.org/10.1177/0270467604264992. Dreyfus, S. & Dreyfus, H. (1980). A five-stage model of the mental activities involved in directed skill acquisition. Fanning, R. M. & Gaba, D. M. (2007). The role of debriefing in simulation-based learning. Simulation in Healthcare, 2, (2), 115–125, http://dx.doi.org/10.1097/SIH.0b013e3180315539. Heitman, E. & Bulger, R. E. (2005). Assessing the educational literature in the responsible conduct of research for core
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content. Accountability in Research, 12, (3), 207–224, http:// dx.doi.org/10.1080/08989620500217420. Horvancsek, M. T. (2007). Using simulation in nursing education. In P. Jeffries (Ed.). Simulation in nursing education: From conceptualization to evaluation. (pp. 1–9). New York, NY: National League for Nursing. Jeffries, P. R. & Rogers, K. J. (2007). Theoretical framework for simulation design. In P. R. Jeffries (Ed.). Simulation in Nursing Education: From Conceptualization to Evaluation. (pp. 21–33). New York, NY: National League for Nursing.
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Peirce, A. & Smith, J. (2013). Ethical & legal issues for doctoral nursing student: A textbook for students and reference for nurse leaders. Lancaster, PA: DEStech Publications. Rudolph, J. W., Simon, R., Rivard, P., Dufresne, R. L. & Raemer, D. B. (2007). Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiology Clinics, 25, (2), 361–376, http://dx.doi.org/10.1016/ j.anclin.2007.03.007. Stenick, N. R. (2007). ORI introduction to the responsible conduct of research. 2007 Retrieved from , http://ori.hhs.gov.
R
ESPONSIBLE CONDUCT OF research (RCR) commonly known as ethics training is an essential
* Associate Professor and Assistant Dean, College of Nursing, University of Utah, Salt Lake City, UT 84124. † Associate Professor and Director, College of Nursing, University of Utah, Salt Lake City, UT 84124. ‡ Assistant Professor (Clinical) and Director, College of Nursing, University of Utah, Salt Lake City, UT 84124. § Assistant Professor (Clinical) and Executive Director, College of Nursing, University of Utah, Salt Lake City, UT 84124. Address correspondence to Dr. Clayton: College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT 84124. E-mail: [email protected] (M.F. Clayton), [email protected] (K. Supiano), [email protected] (R. Wilson), [email protected] (M. Lassche), [email protected] (G. Latendresse) 8755-7223 Journal of Professional Nursing, Vol 0, No. 0 (June), 2016: pp 1–6 © 2016 Elsevier Inc. All rights reserved.
component of graduate scientific education and a critical component of professional behavior (Anderson et al., 2007; Heitman & Bulger, 2005; Peirce & Smith, 2013; Stenick, 2007). However, while simulation has become a standard educational approach to teach clinical nursing skills, little has been done with this approach in nonclinical programs, for example doctor of philosophy (PhD) programs offering scientific educational preparation (Fanning & Gaba, 2007; Horvancsek, 2007). In PhD programs, ethics education is traditionally didactic and is a component of the core curriculum early in a student's course of study. However, when students move forward to the implementation phase of their dissertation, we have found that questions persist or arise regarding application of these principles. Revisiting the application of RCR principles prior to students beginning their independent research may help students navigate unexpected “real life” situations, facilitating 1 http://dx.doi.org/10.1016/j.profnurs.2016.05.010
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presenting more research challenges rather than basic knowledge. This approach to development helped us create scenarios that would assist students to apply their knowledge to potential research quandaries that might occur during the conduct of their independent research. The final step in simulation-based education is to debrief participants. Debriefing and feedback are considered to be the most important phase of experiential learning (Cheng et al., 2014). Facilitated structured debriefing helps learners to reflect on their performance and consider what the experience means in terms of future practice (Decker et al., 2013). Ideally, debriefing occurs in a psychologically safe environment with a skilled facilitator focused on the identified learning outcomes (Decker et al., 2013).
ethical and appropriate solutions to commonly encountered research situations.
Purpose The overarching purpose of this project was to develop, implement, and evaluate two simulated scenarios in PhD education. Scenarios incorporated potential areas of confusion and common questions about RCR previously observed by PhD program faculty during supervision of dissertation research. Facilitating student application of RCR principles prior to conducting their dissertation research has the potential to decrease risk for inadvertent research misconduct.
Simulation Pedagogy Simulation is a common approach to providing active, experiential learning. When designing simulation exercises, it is essential to match the complexity of the scenario and the content of the scenario to learner needs, creating a situation that is challenging but not overwhelming (Jeffries & Rogers, 2007). An education matrix is a novel tool that is useful for calibrating a simulation-based experience. With lesser expertise, basic knowledge is provided. As expertise is attained, the focus on knowledge lessens, shifting to essential and supporting competencies, which also lessen as expertise increases and, finally, to increasingly complex challenges that are presented to the most experienced learner. Figure 1 illustrates the shift from knowledge to competency to challenge and presentation of increasing complexity as learner expertise is attained. Increasing complexity is indicated by more + marks in the table. This approach is based on a task analysis framework that has been used to structure simulation-based training in the U.S. Air Force (Alliger, Beard, Bennett, Colegrove, & Garrity, 2007) and models of skill acquisition (Dreyfus, 2004; Dreyfus & Dreyfus, 1980) (Figure 1). An educational matrix accounts for increments in skill performance based upon experience and education, allowing us to build scenarios that matched our student needs and experience level and evaluate student performance. Because our participants were PhD students who had completed didactic ethics training, we focused on
Methods As a direct result of expressed faculty concerns about retention of ethical content based on supervision of students conducting their dissertation research, a task force of nursing PhD program faculty was formed. Simulation was suggested as one way to help students apply learned ethical principles; thus, simulation faculty and experts joined the task force. After robust discussion of commonly experienced ethical dilemmas, two scenarios were developed. Although this project was educational in nature, we obtained institutional review board (IRB) approval so that we could more widely disseminate findings from this novel approach to scientific ethical education. Another reason for obtaining IRB approval was to role model what we were teaching students. Scenarios were piloted with 11 second and third year nursing PhD students who had not yet begun their dissertation research. The simulation laboratory provided a safe controlled environment where students could apply learned didactic principles of RCR, offering faculty a way to further integrate RCR principles into our PhD program. As is customary in simulation pedagogy, we used videotaped scenario observational data to evaluate student performance in relation to an educational attainment matrix. Grades were not assigned to student participants. To help us appreciate how we might
Challenges
++
+++
++
+++
++
++
+++
++
+
+
Content Stratification
Supporting Competency Essential Competency
CLAYTON ET AL
Skill
++
+++
++
Knowledge
+++
++
+
Novice
Adv. Beg
Competent
Proficient
Expert
Learner Developmental Level
Figure 1. Educational Matrix indicating a shift from the provision of basic knowledge to complex challenges as learner expertise increases. 1 1Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.
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evaluate the use of simulation in PhD education and move this project forward, we asked a member of our university's Center for Teaching and Learning Excellence to observe the implementation of scenarios. The observer prepared a formal written report and shared it with PhD program faculty and other faculty participants.
Scenario Development The RCR taskforce met several times to develop scenarios and determine the most appropriate learning objectives for each scenario. High-fidelity simulation using live actors as the scenario leaders and confederates (other scenario participants) was determined to be the most appropriate methodology for simulation delivery to elicit both the cognitive, emotional, and affective components of conducting independent research among PhD students. Two scenarios were developed to enhance the PhD curriculum. Scenario One addressed the addition of an instrument that would enhance study findings, discussed in a research meeting. The scenario ended when the student recognized the need to submit an IRB protocol amendment. Objectives for this scenario included specifically recognizing the need for an IRB amendment when a protocol change is deemed necessary, asserting the need for an IRB amendment while maintaining a collaborative affect with the research team and verbally advocating for the IRB amendment. Students were also given an opportunity to challenge authority and take ownership of their research. Scenario Two simulated an in-home survey data collection experience with an elderly participant and her adult daughter who provided progressively more answers to researcher questions as the elderly participant's fatigue increased. The scenario ended when the student indicated awareness that data obtained from the nonconsented daughter are neither IRB approved nor valid and suggested alternatives such as a second home visit to complete data collection. Objectives for Scenario Two included recognizing family member interference in study participant responses, understanding that the participant is the only person who should answer the survey questions, and intervening using a respectful and collaborative demeanor with the increasingly assertive family member. Facilitation and student guidance during scenarios were provided by faculty actors posing questions as cues related to desired learning outcomes as the scenarios unfolded. After the scenarios were written, a scenario leader and confederate (defined as other actors in the scenario) scripts were created for both scenarios to ensure that all graduate students received the same standardized simulation. Both scenarios were vetted by PhD experts and peer reviewed by four content experts prior to delivery.
Participants Six faculty volunteers served as scenario leaders and scenario confederates. Faculty volunteers were trained in facilitation of their scenarios. Faculty were carefully advised on issues of student confidentiality and the
3
nongraded nature of these exercises. To help students to suspend disbelief and participate fully in the scenarios, we cast faculty as actors outside their usual faculty roles. For example our Scenario One “statistician” was portrayed by a gerontologist faculty member, and our elderly research participant directs one of our Doctor of Nursing Practice specialties. All second and third year PhD students were invited to participate. Eleven student participants individually participated in both scenarios (every student experienced both scenarios) representing all students enrolled in their second or third year of coursework. Student participants were all female and 32–53 years of age (mean = 40 years). Two were Bachelor of Science in Nursing-PhD students, 9 were Master of Science in Nursing-PhD students (5 students had Master of Science in Nursing degrees; the other 4 had allied health master’s degrees but were not nurses); 2 of the 11 participants were international students. There were no exclusion criteria. Students were informed that simulation exercises designed to enhance their knowledge of RCR were planned as a special educational event. Informed student consent was obtained for participation and to videotape scenarios for later analysis, scholarly dissemination of findings, and educational purposes. Information about the project was presented to the entire group of students in a single session to allow for a collaborative atmosphere where all participants could ask questions, with the added benefit of all participants hearing the same information and answers to any questions. After all questions were answered, students independently chose to participate or not and were free to leave the simulation laboratory. No students declined participation.
Setting Scenarios were implemented in the clinical simulation center within our college of nursing. A room configured in a conference room style was used to simulate the research team meeting associated with Scenario One. Scenario Two used a “living room” style room to simulate a furnished home environment. These rooms were considered similar to typical conference rooms and household family rooms as a way to optimize the balance between experimental control and ecological validity, in addition to optimizing fidelity in simulation pedagogy. All rooms in the simulation center are outfitted with unobtrusive ceiling-mounted pan–tilt–zoom cameras. All sessions were video recorded by a simulation operations specialist. Simulation operations specialists all completed the Collaborative Institutional Training Initiative (CITI training) and were authorized to participate in human participants' research.
Scenarios in Action The simulation day consisted of an initial group information session, individual consent, simulation scenario prebriefing, simulation activity by participants, flash debriefing, and a final group debriefing. Following consent, all participants were prebriefed regarding the
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simulation experiences using a standardized script. Participants received clipboards, pens, and a copy of the prebrief to review and write notes on prior to the simulation experiences. Questions were answered regarding each simulation experience, and all participants were given a schedule for their “simulation appointment.” This allowed participants to come and go as needed between individual simulation appointments maximizing use of student time and respecting their other commitments. Participants were on their honor not to discuss scenarios with others until the group debriefing had occurred. In addition to the schedule, a “green room” was provided where participants could choose to relax and wait in a quiet area before and after their simulation appointments. Debriefing was scheduled as a group at the end of the simulation day. This allowed participants to gain understanding and learning from peer-to-peer interactions.
Debrief A very brief “flash” debrief was conducted privately with each student immediately upon completion of each scenario to gauge student responses, emotional experiences, and answer immediate questions. It was here that misconceptions were discovered that were then able to be addressed generally (and anonymously) in the more formal group debrief. For example, one student commented in her flash debrief that she would simply disqualify the elderly patient rather than attempt a second data collection appointment. This led to a later group discussion of statistical power and length of recruitment time for a study and the ethical responsibility to participants and participant respect without drawing undue attention to the individual student. Another flash debrief student comment mentioned that it was more important to keep going with the study given that submitting an amendment would take “forever,” fostering a later discussion of how an IRB functions and how students can keep abreast of the progress of an amendment. The rationale for and pros and cons of changing a research protocol were also discussed. This comment raised the question of how to handle data from participants who had completed the study prior to an anticipated protocol change and who had not received the new instrument. Other general issues identified in flash debrief and discussed in group debrief included how to manage and educate the adult daughter answering questions for her mother and how forceful a researcher should be versus how polite when interacting with an increasingly insistent family member who is not part of the study. A comprehensive group debriefing was held when all students had completed all scenarios. Our goal was to facilitate student engagement and shared self-reflection in a safe and constructive manner with appropriate faculty feedback and discussion. According to Rudolph, Simon, Rivard, Dufresne, and Raemer (2007), “goals of debriefing include allowing students to explain, analyze, and synthesize information and emotional states to improve future performance in similar situations” (p. 361).
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Despite being a nongraded activity, we anticipated that students would experience some “performance anxiety” as they engaged in the simulations. We proceeded in the group debrief with the assumption that our students were motivated to learn RCR and become capable researchers and that faculty would respectfully share honest, rigorous feedback in a nonjudgmental manner. The faculty member conducting the debriefing for our PhD students was a trained and licensed PhD-prepared social worker with decades of clinical and research experience handling difficult emotional situations. This background was instrumental in her ability to draw out student feelings of inadequacy and possible reasons for these feelings in group discussion that avoided singling out any particular student, then to shift the discussion to the scenario objectives and reinforce learning points, opportunities, and solutions that encompassed RCR principles. Faculty were also debriefed as a group to discuss their opinion of using simulation of RCR principles to enhance our PhD program and for their experiences as actors. Suggestions for revision and improvement were discussed in both student and faculty group debriefing sessions.
Results Results indicated students were supportive of simulation and that learning had occurred with student misconceptions corrected in a safe learning environment. Six students had extensive prior research experience as part of their employment, three had limited research experience (e.g., as a Research Assistant), and two students had no prior research experience. We observed that students with less research experience and younger students were initially concerned with getting the “right” answer as opposed to developing solutions to posed situations. With actor encouragement and facilitation, all students successfully completed both scenarios. Common RCR principles that students had trouble applying during Scenario One (addition of a new survey instrument) demonstrated that not all students appreciated that a consent form is a contract between the participant and researcher with respect to obligations, benefits, and risks. Students also evidenced some confusion on what behaviors violated informed consent. When faced with excitement from research team members about including the additional instrument, some students did not explicitly realize an IRB protocol amendment would be necessary, although all students mentioned in some fashion that the IRB would need to be involved. During debriefing, it was apparent that students were universally afraid of interactions with the IRB and felt that this would inordinately delay study progress. Discussions helped students to appreciate that the IRB is not “out to get them,” that amendments can be completed in a timely manner, and that amendments are needed when participant obligations change (i.e., the need to complete an additional instrument). Observations from Scenario Two showed that students with more clinical experience had trouble relinquishing
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the familiar clinician role and adopting the less familiar researcher role in the “home” environment when faced with a fatigued participant and a daughter providing participant data. Some students tried very hard to be polite to the participant's family member to the detriment of valid data collection. Students stated in debriefing that they were surprised when guided to a solution of a second home visit by faculty facilitation. They did not realize that the solution was “that easy.” When discussing the solution of a second home visit during debriefing, some students said that they initially felt that they did not want to “bother” the family with a second appointment; however, they recognized the benefit of this approach when respect for the highly fatigued participant and the validity of the data were discussed. In addition, other RCR points were stimulated including a discussion of who might actually fill out a survey in this family if it was mailed instead of administered in person in the home environment. Recommendations for revision and improvement from faculty and students alike were to use paid actors rather than volunteer faculty. Faculty cited the time required to implement scenarios, feeling that this could be decreased. Students discussed the desire to not be seen as less capable when attempting to apply RCR principles in front of faculty they might wish to ask to be on their supervisory committee. Faculty also commented during their debriefing that they were highly supportive of continuing to use simulation as a way to enhance our curriculum and wanted to participate in ideas for development of future scenarios.
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Conclusion Evaluation of student solutions to unfolding scenarios illustrates the need for greater opportunities to apply RCR principles as students prepare to conduct their dissertation research. RCR principles learned in early didactic courses are not uniformly applied when students are presented with “real life” situations during simulation. The simulated high-fidelity environment allowed students to immerse themselves in the potential issues associated with conduction of RCR on emotional and pragmatic levels rather than just intellectually in a theory discussion or case study. Our results indicate that using simulation to practice and reinforce RCR principles helps students' ability to make appropriate decisions and apply ethical principles in a safe and controlled environment. Additional ways that we are reinforcing the application of ethical conduct of research include incorporating guest speakers from the IRB and other departments on a regular basis into scheduled student activities. In summary, the use of RCR simulation exercises to exemplify real-life research dilemmas is one way to enhance preparation of students to conduct their own dissertation research and evidence excellence in the responsible conduct of research. Simulation pedagogy holds great promise for application to the learning of RCR skills for future scientists.
Acknowledgments The authors gratefully acknowledge the assistance of participating faculty and the Center for Teaching and Learning Excellence at the University of Utah.
Discussion
References
Overall, this project grew out of faculty observations that students were not consistently able to apply RCR principles during independent dissertation research. Faculty were frustrated when they discovered that inappropriate solutions had been implemented on the spot, leaving them in a difficult supervisory position. Students were frustrated because they intellectually understood didactic content delivered during their first semester, but they had less knowledge about how to implement solutions to more pragmatic situations that could occur during the dissertation phase of their PhD program. Thus, the idea of using simulation to allow students a safe place to practice and apply RCR-based solutions to common research situations was developed. Faculty voiced the need to “hard wire” redundancy of content in different ways to cement student learning. Carrying this project forward, we have continued the work of our RCR PhD program faculty task force, developed a tool box of resources for faculty supervising students, held regular forums where faculty discuss supervisory issues of students with other faculty to gain ideas on best supervisory practices, and incorporated feedback from both faculty and our Center for Teaching and Learning Excellence expert as we develop a library of scenarios that will be rotated and implemented during the PhD program of study for all students.
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