Abstract
Clinical simulation offers an alternative to naturalistic inquiry of phenomena in health care that are ethically and logistically difficult for researchers to access firsthand. However, whether it is a similar experience, and the extent simulation elicits data that is meaningful for the real-world phenomenon under investigation is unknown. To address this gap, we explored the experience of 18 paediatricians who were participants in our wider phenomenological simulation-based study of communication practices related to paediatric advance care planning. We identified that: (1) the simulation felt real despite differences to reality, and (2) the paediatricians’ consciousness of their involvement in research condensed the pace of the advance care planning communication process but did not change their overall approach. In summary, simulation as an investigative method can enrich the understanding of the phenomenon of interest. These findings should encourage researchers to consider simulation for future qualitative inquiry.
Keywords
Introduction
Clinical phenomena that occur infrequently and involve vulnerable populations are difficult for researchers to access firsthand (Hales et al., 2018; Marshall et al., 2018; Mills et al., 2016; Stockmann, 2017; Vemuri et al., 2020). Communication in preparation for end-of-life decision-making for a child with a life-limiting condition, otherwise known as paediatric advance care planning (ACP), is one such phenomenon. These discussions are uncommon and usually occur at highly emotional times when the child is critically unwell (Carter et al., 2004; Kelly et al., 2018), or when the need or opportunity arises in clinical encounters. As a result, they are unpredictable in timing, making opportunities for naturalistic inquiry limited. Research into this phenomenon remains a high priority (Baker et al., 2015) as high-quality communication can be helpful to parents when approaching their child’s death (Bateman et al., 2016; Boss et al., 2014; Doorenbos et al., 2012; Mitchell et al., 2019), to minimise parental regret about care provided at these times and ideally, reduce the risk of unresolved grief and complicated bereavement (Meyer et al., 1996). However, naturalistic inquiry involving direct observation and recording of this communication process is logistically and ethically problematic. Logistically, these discussions do not occur often, are rarely planned, and may arise spontaneously; a large number of interactions may need to be observed and recorded to capture relevant data related to ACP discussions. The costs may be prohibitive in terms of researcher time and funding. Ethically, these discussions often occur at highly emotional times (Carter et al., 2004; Kelly et al., 2018) and this confers a potentially significant risk to parents in participating in such research, which would be multiplied many times by recording many interactions in order to capture the relevant one or two. Risk in this context relates to potential intrusion into the privacy of parents, parental psychological wellbeing, and erosion of the therapeutic relationship. In fact, it is ethically challenging even to seek consent from parents for such research. Parents would be asked to consent to observation and recording of a consultation without them necessarily knowing in advance the content of the conversation. Further, informing parents that the research is related to preparation for end-of-life decision-making could in itself cause distress and is likely to significantly change their interactions with their child’s doctors, and the therapeutic relationship between them. If parents are informed of the content of impending conversations through the research consent process before being raised by the clinical team, trust in their child’s paediatrician may be eroded, their understanding of their child’s condition may be altered, and the nature of the planned consultation may be influenced. The alternative is to not disclose to parents the purpose of the research when seeking their consent to participate, which would be a significant erosion of informed consent, and likely to cause distress later when parents were informed or found out for themselves. These challenges create problems for completion of research and limits generation of much needed knowledge and evidence.
To date, most of the research into paediatric ACP has involved retrospective reports from clinicians and bereaved parents. This only develops our understanding up to a point (Lotz et al., 2015, 2017; Vanderhaeghen et al., 2019; Vemuri et al., 2022). Clinical simulation offers a feasible alternative to naturalistic inquiry to continue to progress our understanding of this phenomena, without the same risks of harm (LeBlanc et al., 2011). Furthermore, through greater control of multiple influences (Dieckmann et al., 2011), simulation can spotlight inquiry on a desired phenomenon within the scenario, such as communication (Vemuri et al., 2020).
Recreating a clinical scenario using specific tools and environments allows clinicians to experience a representation of reality (Cook et al., 2011). Clinical simulation is widely used and known to be effective in teaching clinical skills (Cook et al., 2011; Gurusamy et al., 2008; McGaghie et al., 2010; Sturm et al., 2008) and it can also facilitate study of systems and human actions (Le Blanc et al., 2011; Lioce, 2020). While inherently different from naturalistic inquiry, use of clinical simulation as a research method can be successful, depending on whether it is “real enough” to allow participants to experience the thoughts and emotions that they would in reality (Dieckmann et al., 2007, 2011), a quality known as “psychological fidelity” (Dieckmann et al., 2007). This enables insight into participant experience and assigned meanings of the interpreted phenomenon (Dieckmann et al., 2007; Munroe et al., 2016), and is necessary to promote trustworthiness of findings when using simulation in the study design for research using an interpretivist methodology. Guidance on conducting simulation-based investigation highlights the need to ensure that the simulation is designed appropriately for the methodology (Cheng et al., 2014; Munroe et al., 2016), but there is no standard approach to assess trustworthiness of research findings when using simulation as the investigative method (Wilson et al., 2018).
As part of previous simulation-based studies, there are descriptions of using post-simulation surveys or interviews and focus groups to prompt participants to reflect and comment on their emotions, thoughts and feelings during the simulation as compared to reality (Barnato et al., 2008; Wong et al., 2017). However, none of these articles have reported these results. We address this gap by reporting on results from our post-simulation interviews which explore the extent to which simulation elicits data that is meaningful for the real-world phenomenon of paediatric ACP. In this article, we will demonstrate that using simulation as the investigative method in a study can enrich the understanding of paediatric ACP.
Methods
Study Design
This study was part of a larger simulation-based study exploring paediatricians’ communication practices of ACP. Our underlying assumption was that individuals interpret reality based on an understanding of events and meanings assigned to language and social interactions (Creswell, 2003). Consistent with this interpretivist epistemology, we adopted a phenomenological framework (Van Manen, 2016) to guide our study design and analysis. We obtained institutional research ethics approval from The Royal Children’s Hospital Melbourne Human Research Ethics Committee (HREC/50340/RCHM-2019).
Paediatricians caring for children with life-limiting neurodisability in Victoria, Australia were recruited via professional networks and snowballing. The context of the communication approach being studied was intended prior to the involvement of palliative care services. This aligns with published parental preferences for ACP discussions to be initiated by their child’s long-standing, trusted, treating paediatrician (Bluebond-Langner et al., 2007; DeCourcey et al., 2019; Mack et al., 2005). As a result, paediatricians who worked within specialist palliative care teams were excluded. Paediatricians who assisted with the study design were also excluded. Purposive sampling was used to obtain spread across seniority, clinical experience in caring for children with life-limiting neurodisability in the outpatient clinic and inpatient intensive care settings, and previous experience with clinical simulation. Participants provided written informed consent prior to taking part in the simulation study, which was conducted between April and May 2021.
Clinical Simulation
We used simulation to recreate two scenarios, which were developed using the clinical experience of three members of the research team (S.V., J.H., and K.W.), in consultation with two subject matter experts (consultant paediatricians with more than five years’ experience working at consultant level in a tertiary paediatric centre: one in neurodevelopmental medicine and the other in paediatric intensive care). S.V. is a paediatric palliative care physician and doctoral candidate trained in qualitative research methods, J.H. is a paediatric palliative care physician and post-doctoral qualitative researcher, and K.W. is a neurodevelopmental paediatrician and post-doctoral researcher (predominantly using quantitative methods). Detail about the rationale for choosing simulation in the research method and its design features have been previously published (Vemuri, Heywood, et al., 2023). The two scenarios involved a child with a life-limiting neurodisability: one in an outpatient clinic setting; the other in the intensive care unit. Two medically trained actors, both with over ten years’ experience in simulation for paediatric communication training, played the role of parents. The actors had also participated in a full-day workshop involving five bereaved parents of children with severe neurodisability. Detailed description of the experience of this workshop is published elsewhere (Vemuri, O’Neill et al., 2022). A manikin was used to portray the child (sleeping in a wheelchair or hospital bed), and simulation room was set up with some features of the clinical setting (e.g., outpatient clinic room desk and chairs or bi-level ventilation mask, ventilator and hospital bed). The aim was to achieve psychological fidelity; the parent-actors, manikin and room set-up were aids for psychological fidelity, rather than fully realistic replication of the physical clinical environment.
The scenarios were designed to recreate a clinical situation in which a paediatrician would: (1) form the view that the child was vulnerable to early death, (2) think about starting a discussion with parents to share these concerns (a type of discussion that is part of ACP), but (3) not feel any urgency to reach specific decisions now about medical interventions not be undertaken when death was approaching. Two independent internationally-based paediatricians confirmed that the scenarios met these criteria. Each participating paediatrician was matched to one of the two scenarios based on their clinical practice. The simulations ran for approximately 30 minutes duration and were observed remotely by members of the research team (S.V., J.O, J.H., and L.G.). The observations informed the post-simulation interviews.
Data Collection
Paediatricians participated in an individual semi-structured interview immediately following the simulation. These audio-recorded interviews were conducted by S.V. and were between 30- to 60-min in duration. S.V. was known to all participants in his clinical capacity. An interview guide (supplementary file 1) was developed by the research team and was rapidly revised and personalised based on the research team’s observation of each individual simulation prior to commencement of the interview. Observed practice within the simulation primed discussion in the interview and prompted more general discussion about each paediatrician’s communication approach extending beyond the simulation. Verbatim transcripts were professionally transcribed and checked. The focus of this study is on the use of simulation in the research method; data from the other areas of inquiry in the interview are not included in this article.
Data Analysis
Inductive content analysis (Elo et al., 2008) was conducted by S.V., J.O. (a bereaved mother, clinical nurse consultant involved in the care of children with neurodisability, and post-doctoral qualitative researcher), J.H., and L.G. (a clinical ethicist and post-doctoral qualitative researcher). We initially familiarised and immersed ourselves in the data by reading and re-reading the first transcripts following the outpatient clinic and intensive care simulations. Following this, we individually open coded these transcripts and then met to collectively produce coding sheets. Analysis incorporated two rounds of coding and discussion; S.V. coded the remaining transcripts, which we all then discussed, revised, and grouped, before categorising them into higher level themes to produce a final schema by consensus.
Rigour was promoted through contemporaneous notes of the robust discussions in our meetings, prolonged engagement with the data and by attention to reflexivity (Creswell, 2003; Elo et al., 2008). Reflexivity was practised throughout this analytic process; S.V. regularly debriefed with members of the research team and took self-reflective notes which were discussed during team meetings. Reflexivity was also enhanced by the interdisciplinary composition of our research team, including L.G. who is not a clinician. Data were managed in hardcopy files and electronically with NVivo (2018).
Results
Participants
Eighteen paediatricians were included: 11 cared for children with life-limiting neurodisability in outpatient clinics and the remaining seven provided care in intensive care units. Thirteen paediatricians had prior experience with simulation. Seniority assigned based on years working at consultant level was spread: six paediatricians had <10 years, five between 10–20 years, and seven >20 years.
Key Themes
Analysis identified two key themes with respect to the extent research findings were influenced by using simulation in the investigative method: (1) The simulation felt real despite differences to reality, and (2) Paediatricians’ consciousness of the study condensed the pace of the ACP communication process but did not change their overall approach.
Theme 1: The Simulation Felt Real Despite Differences to Reality
Paediatricians in this study commented on the appropriateness of scenario being simulated when compared to reality, and the adequacy of this recreation. These comments were not influenced by the paediatricians’ previous experience with simulation. For some paediatricians, the simulated scenario they participated in differed from their practice: “the reality [is] I wouldn’t be sitting by the bedside, not unless the child’s actually deteriorating and I actually wanted to usher them [parents], deliberately usher them into [another] room and do that talking [there]” (P13).
However, this view was not shared by all, as others described that the simulated scenario appropriately recreated a scene they commonly encounter: “it was a typical scenario that I see…pretty similar to what we see in real life” (P8).
The adequacy of the replication of reality was referred to in comments about the artificialness of using the child manikin and the influence of the actors playing the role of parents within the simulation. The impact of the child manikin varied between paediatricians regardless of their previous experience with simulation. As one paediatrician described: “the most disturbing part for me…‘cause I feel like when I do normal consultations, I do interact with the child quite a lot…[the child manikin] kept reminding me that it was a simulation” (P4).
Whereas another paediatrician shared: “obviously having a [manikin] is difficult but I think it’s unavoidable in terms of those things, and I wasn’t really put off by that….like you had warned me that that was the case” (P6).
All paediatricians in the study described that the actors playing the role of parents contributed to making the simulation feel real. This is illustrated in the comment by one paediatrician: “they do a fantastic job, those actors, they were very realistic…[they] must have lived experience, and I was completely fooled…it was very realistic in terms of the interaction” (P6).
This was further explained by another paediatrician with extensive experience in simulation training: “[whenever] you’re doing an intervention and you’re not seeing a response, or you’re seeing a response but it’s a fake response that’s a different story, that’s where it looks fake….for all practical purposes this is simulation…I’m talking to you as a real person, when I’m talking to them [actors] it was a real scenario, you’re talking on real stuff, so I had no concerns that this is fake” (P17).
Theme 2: Paediatricians’ Consciousness of the Study Condensed the Pace of the ACP Communication Process but did not Change Their Overall Approach
While feelings of realism were achieved in the simulation, most paediatricians remained conscious of the research study and anticipated its objectives. This consciousness was described amongst paediatricians with and without experience with simulation. As one paediatrician described: “your mind is so aware of everything and that you’re conscious that you’re not missing the cues that they’re giving you…knowing it’s a simulation so you’re like ‘what else am I missing?’” (P13).
Another paediatrician shared that: “I was conscious that there might have been an agenda where [the actors] were asked to go…and so I was, there were some times when [they] jumped out with stuff I thought hold on there’s an agenda, we’re meant to be going somewhere” (P15).
As a result of this consciousness, many paediatricians described they increased their pace of initiating the ACP communication process. This is evident in the reflection of one paediatrician: “I definitely would’ve had a choice to park [initiating ACP]. I think I was influenced by the fact that I was doing a, doing a sim, and I knew you’d be interested in that. I reckon that definitely came into my thinking because I think I probably in real life might’ve parked it” (P4).
However, all paediatricians agreed that despite this change in timing, their approach mirrored reality. This is reflected by one paediatrician who shared: “I wouldn’t have handled it in any different sort of way, like I felt like I feel when I’m answering questions to parents… I felt constrained by my usual ways of practicing…I wondered did I lead myself here by digging too deep for the purpose of the simulation or was this, would this have happened in reality? And it could have happened in reality and if it wasn’t that time, it would have been another time” (P6).
Discussion
Paediatricians working with children with neurodisability and their families reported that their behaviour and experiences in the simulation were similar to their clinical roles even though they noticed some differences to reality. Our results indicate that using simulation in the investigative method to explore paediatricians’ communication practices of ACP enabled an interaction that felt real to participants despite these differences. While our research findings were influenced by using simulation, this influence enriched our understanding of ACP. Using observed practice within the simulation to prime and prompt discussion in the interview, which is unique to our study, afforded an opportunity to triangulate paediatricians’ self-reported practices with observations from the simulation, and seek clarification about the intention behind observed communication practices. Discussion related to the entire ACP communication process following observation at a single time-point was facilitated. This priming provided a level of detail that has not been achieved in retrospective clinician reflections of ACP discussions, linking intentionality to observed practice.
Our findings also support the importance of mimicking a situation whereby the participant experiences the emotions, beliefs, and thoughts of reality when using simulation. This is psychological fidelity and is distinct from the authenticity of the physical environment (Dieckmann et al., 2007). The relative importance of psychological fidelity in comparison to physical or environmental fidelity in enhancing realism for communication-based simulations is well established in simulation-based education literature (Borghi et al., 2021; Cook et al., 2011; Dieckmann et al., 2007; McGaghieet al., 2010; Meyer et al., 2011) and emerging in the simulation-based research context (Lu et al., 2015; Munroe et al., 2016; Vemuri et al., 2020; Wong et al., 2017). Muckler (2017) notes that enhanced psychological fidelity helps participants suspend their disbelief and accept otherwise unrealistic components of the simulation. This was evident in our study findings. Despite being constantly aware of the research focus of the simulation, variability in paediatricians’ thoughts about the appropriateness of the scenario with respect to clinical practice, and use of the child manikin, paediatricians described that the simulation felt real, and their overall communication approach was not influenced. In this study, suspension of paediatricians’ disbelief was unanimously attributed to the skill of the actors to help make the simulation feel real.
The value of actors in simulation (Pascucci et al., 2014; Pritchard et al., 2020), and measures to assist in their character development (Starr et al., 2021; Vemuri, O'Neill, et al., 2022) are well described. Through their interaction, actors can add richness and depth to the simulation, and have been identified as specialists in this field (Pritchard et al., 2020). Furthermore, by being experts in communication, actors can also afford an opportunity to enhance the analytic process by providing data following the simulation that support or contradict themes identified by researchers. This level of data triangulation is not possible in naturalistic inquiry, and may be enhanced if, as was the case in this study, the same actors are involved in all simulations. While findings related to the ACP communication process are outside the scope of this article and are being prepared for publication elsewhere, we want to highlight that we have engaged the actors to triangulate data from the paediatrician’s post-simulation interviews about ACP, and this adds a level of rigour to our wider study’s findings. We recognise that the two actors employed in this study have worked closely together previously and are comfortable working with clinicians and in healthcare settings. Given their influence on the trustworthiness of this research method, we acknowledge that other actors may not have achieved this same effect in achieving realism for participating paediatricians.
Concepts such as psychological fidelity and realism in simulation have arisen from social theory and have been most widely considered in simulation-based educational initiatives (Dieckmann et al., 2007; Vemuri et al., 2020). While they are equally applicable for consideration in qualitative research, our findings in this study might be influenced by clinicians’ familiarity with S.V in two ways. On one hand, this familiarity may have resulted in more positively described experiences of simulation in the research method. On the other hand, familiarity with S.V. may have enhanced participants’ openness and honesty in its critique (Holloway et al., 2011; McConnell-Henry et al., 2009). Given that differences in responses between clinicians were still observed, we believe that such influence is minimal. Interestingly, we found that prior experience with simulation did not appear to impact on paediatrician’s experience within this study, although we note that individual participant factors, such as how one assigns meaning and their capacity for emotional buy-in can influence their ability to immerse in simulation-based education (Muckler, 2017). These individual participant factors may influence the success of simulation as an investigative method and warrants further study.
Conclusion
Despite being inherently different to reality, clinical simulation offers a viable alternative to naturalistic study of phenomena that are difficult to access firsthand. We have demonstrated that by achieving psychological fidelity, largely by using actors, participants are able to suspend disbelief contributing to the trustworthiness of this research method and its findings. The influence of simulation can enrich the understanding of the phenomenon of interest, and these results should encourage researchers to consider simulation for future qualitative inquiry.
Supplemental Material
Supplemental Material - Is Simulation as an Investigative Method as Good as Reality?
Supplemental Material for Is Simulation as an Investigative Method as Good as Reality? by Sidharth Vemuri, Jenny O’Neill, Jenny Hynson, Katrina Williams, and Lynn Gillam in International Journal of Qualitative Methods
Footnotes
Acknowledgments
The authors are grateful for the support of Dr Giuliana Antolovich and Dr Thomas Rozen for their assistance in scenario development, and Dr Lucinda Carr and Dr Thomas Brick for their assistance in assessing face validity of the scenarios.
Author Contributions
S.V. conceptualised and designed the study and interview guide, collected data, carried out data analysis, drafted the initial manuscript and reviewed and revised the manuscript. J.O. revised the interview guide, collected data, carried out data analysis, and reviewed and revised the manuscript. J.H. and L.G. conceptualised and designed the study and interview guide, supervised the data collection, carried out the data analysis and reviewed and revised the manuscript. K.W. conceptualised the study and reviewed and revised the manuscript. S.V. accepts full responsibility for the overall content as the guarantor and all authors approve the final manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Bethlehem Griffiths Research Foundation (BGRF2007) and the Melbourne Disability Institute at The University of Melbourne. S.V. is supported by the Australian Government Research Training program, provided by the Australian Government and The University of Melbourne.
Ethical Statement
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
