Co-Constructive Patient Simulation as an Experiential Tool for Continuing Professional Development in Healthcare

ABSTRACT

In this commentary, we examine how to use the recently developed educational method called Co-constructive Patient Simulation (CCPS) to improve continuous professional development in healthcare. CCPS invites learners to participate in the creation of meaningful simulated scenarios while fostering reflection-in/on/for-action and community-building. By participating in the creation of the simulated scenarios, learners guarantee that the challenges addressed by the learning activities are aligned with their developmental stages and needs. Additionally, as learners may invite supervisors to take the “hot seat” during the simulation session, the CCPS approach allows learners to witness how supervisors would handle situations perceived as challenging. This exchange of roles creates an opportunity for camaraderie, as supervisors expose themselves and assume a vulnerable position. This camaraderie facilitates educational bonding and community building. As a result, in this participatory and co-creative approach to simulation, experts become the facilitators of a learner-centred activity, which increases motivation and allows tailored and contextualised learning. This co-constructive approach to simulation adds to the repertoire of more traditional CPD strategies by fostering spontaneity and authenticity. It integrates learning opportunities in clinical practice, amplifies learner’s critical reflection and autonomy, and harnesses real-life challenges to offer meaningful solutions to lifelong learning. The democratic environment optimised by experts joining the activity and sharing their vulnerabilities with trainees further catalyzes the creation of a community for teaching, learning, and shared development.

Keywords:

• Simulation
• Continuous Professional Development
• Lifelong Learning

Human simulation is a powerful tool in healthcare education [1,2]. It allows the reproduction of real-world challenges in a safe space where learning is facilitated by an expert who fosters reflective practice while, on, and for doing [3–5]. Until recently, simulation exercises have relied on experts to create meaningful scenarios conducive to learning. These experts may include but are not limited to experienced clinicians, nurses, or physiotherapists. We posit that such an expert-centred approach may have at least three pitfalls:

1. Experts have complex cognitive structures such as well-honed pattern recognition, which allow them to jump foundational steps when solving problems. Considering their acquired efficiency, experts often struggle to understand the challenges faced by less experienced practitioners.

2. Learners, particularly in continuing education, have different needs, and work in contexts that may be unfamiliar to the supervising experts [6].

3. Creating cases may miss the educational mark when exclusively designed by experts. For example, experts can design overly challenging scenarios that result in participant’s frustration rather than mastery.

In this commentary, we examine how to overcome those challenges in creating simulated experiences that are conducive to meaningful continuing professional development (CPD). We consider as meaningful those situations that mirror the complexity of trainees’ current practice and that help them advance to their next zone of proximal development [7,8]; i.e. to contextualise genuine situations that invite transformative learning.

Two of the authors (MAdCF and AM) have created a new approach to human simulation, “co-constructive patient simulation” (CCPS) [9], which has since been applied in postgraduate settings in psychiatry [10] and in veterinary medicine [11]. Briefly, in the CCPS methodology, learners share the responsibility of creating simulated scenarios, based on experiences in their practice they have been challenged by. We share here some of our insights gained and lessons learned during the first four years implementing this approach. We hope that by doing so, we may spark the enthusiasm of fellow educators and healthcare professionals working with CPD in healthcare. We go on to outline four novel aspects of CCPS that with relevance to the CPD community.

The Learner at the Lead

In CCPS, it is the learner who takes ownership in elaborating a simulated scenario based on real-life challenges not yet fully metabolised and thus providing potential opportunities for their professional growth. This real-life focus brings authenticity into the simulation lab and nurtures the trainees’ autonomy, which serves as a potent intrinsic motivational factor. After selecting the lived situation, which can be based on an amalgam of different experiences, trainees engage with professional actors who serve as simulated participants (SPs), in designing their cases and scenarios. From the outset, case development already provides a reflective and learning experience for all involved. A content and/or simulation expert may join the team to facilitate the process, to help co-create the case, and to ensure an essential element of a successful simulation session, namely, to articulate concrete learning objectives.

Sharing the Challenge

In CCPS, fellow learners or an expert blinded to the case take turns in the “hot seat” interviewing the character embodied by the SP. The opportunity to see how a peer or an expert would handle the same challenging, lived clinical situation is singular. It creates connection and complicity, a sense of comradery and belonging, builds trust, and invites democratic and bilateral dialogue and feedback.

Simulation as a Means Not an End

CCPS requires a specific approach to debriefing, a model inspired by Schon’s levels of reflection: in-action, on-action, and for-action [3]. Rather than being an end in itself, the simulated scene triggers a meaningful learning experience. Specifically, the group jointly explores what happened in the scene, without taking a judgemental stance. A facilitator may help explore moments in the encounter that serve as entry points into a reflection-in-action process that in turn fosters a meta-cognitive perception of the situation. The process is akin to enhancing “scenic intelligence”, a kind of self-directing ability conducive to mindful, in-the-moment practice [12]. Early in their careers, actors rely on directors’ feedback to improve their performance and sharpen their characters. At this point in their careers, actors are often unable to look over themselves during the actual scene and identify points for improving the quality and authenticity of their representations. Thus, the guidance of a director is fundamental. As actors become more experienced, they develop a capacity to assess their performance while performing. It does not imply that directors are no longer useful; rather, that actors have become more autonomous and “in control” of their performances.

Similarly, when healthcare professionals are dealing with unexpected, complex situations, the capacity for auto-regulation, insight generation, and adequate response may not be optimal, leading to frustration. The opportunity to come back to that specific situation while preparing a simulated case and observe how colleagues would handle this case may nurture their capacity to deal with similar complexity in the future by increasing their self-awareness and repertoire of reactions.

Next in the debriefing, during the reflection-on-action process, the group maps out challenges inherent to the simulated case and possible approaches to those challenges: those used by the group and others that could still be pertinent. Finally, the reflection-for-action component focuses on the future situations in which the experiential learning could become relevant: an exercise in making sense of the experience and identifying concrete take-home messages.

Community-Building Through Simulation

In CCPS, debriefing happens in a horizontal and democratic dialogue and explicitly aims to create a sense of community. Moreover, when applied throughout a longitudinal experience, it permits the creation of a community of practice with a strong shared identity [13,14]. The creation of this community allows the conversation to go beyond the desirable behaviours or clinical solutions to embrace a critical evaluation of personal and professional values. It allows the conversation to search for mechanisms to achieve “professional phronesis”, aligning beliefs, values, and actions. These mechanisms involve personal, contextual, and structural dimensions, which intertwine to facilitate or constrain this alignment. All these dimensions may be manipulated in simulated sessions, and diverse responses can be idealised and tested: the CCPS session functions as a rehearsal for actual practice.

In summary, in this participatory and co-creative approach to simulation, experts become the facilitators of a learner-centred activity, which increases motivation and allows tailored and contextualised learning. The democratic environment optimised by experts joining the activity and sharing their vulnerabilities with trainees further catalyzes the creation of a community for teaching, learning, and shared development. Such a community may fuel both trainees’ and experts’ lifelong learning behaviours. The co-constructive approach to simulation adds to the repertoire of more traditional CPD strategies by fostering spontaneity and authenticity. It integrates learning opportunities in clinical practice, amplifies learner’s critical reflection and autonomy, and harnesses real-life challenges to offer meaningful solutions to lifelong learning [15].

Disclosure statement

No potential conflict of interest was reported by the authors.