Use of Simulation and Standardized Patients in an Online Genetics Program

Introduction

Boise State University launched a unique online Master of Science in Genetic Counseling program in the Fall of 2019 to expand access to Accreditation Council of Genetic Counseling (ACGC) accredited programs. Most other Genetic Counseling programs are face to face or have on-the-ground requirements which are located in primarily large urban medical centers. Location is one of the factors that limits access to the profession and is reflected in the lack of diversity in the workforce (National Society of Genetic Counselors [SGC], 2020). Online programs are often nimbler in curriculum development and delivery while maintaining the high quality found in traditional in-person programs.

Statement of Problem

As an online program, Boise State had to adapt the rigorous accreditation standards designed for face to face programs by using innovative, interactive learning opportunities to provide students with a comprehensive education to be skilled healthcare professionals. One of these components is preparation for clinical training which is often accomplished in genetics education with the use of role playing or simulated patient experiences (Holt, et al., 2013).

As such, it may be that an online program could take advantage of the use of Simulated or Standardized Patients (SP) for the purposes of practice and formative evaluation of student skills in a virtual or telehealth format. Due to the rural nature of states like Idaho, communication by telehealth or telemedicine is often the most cost-effective and expedient method for Genetic Counselors to deliver patient care. A telehealth SP experience would allow students not only to learn crucial Practice Based Competencies but also gain exposure to delivering genetic counseling services in a telehealth environment.

Another advantage to employing a telehealth SP experience is as support when face to face encounters are not available. In 2020, most large institutions (education and healthcare) suspended on site non-critical operations in order to address the healthcare crisis related to COVID-19. This meant that student clinical training as well as traditional face to face SP experiences were no longer accessible. Although a worldwide event is rare it may be useful to have other, virtual, educational strategies in the curriculum.

Simulated patient encounters for teaching have been utilized with face-to-face Genetic Counseling programs, but telehealth training encounters have not been studied or documented in the literature. For this project, the researchers pose the following question:

Method

The research team utilized recommended best practices (International Nursing Association for Clinical Simulation and Learning [INACSL], 2016) to develop a telehealth simulation scenario which employed an SP. The scenario included objectives written to meet course and program outcomes, faculty overview of the process, student preparation materials, written tools for student feedback, a debriefing guide, and a scenario specific SP training guide. The scenario was adapted from a case study provided by R. Lynn Holt, Meagan Farmer, and the University of Arkansas Medical Sciences. A pedigree of the patient’s family history was created to accompany the student materials.

Upon initial completion of the scenario, the team scheduled a pilot test of the scenario that was conducted via a web-based video conferencing tool called Zoom. A faculty member played the role of the student and an experienced SP was engaged to portray the patient. After the pilot was completed, notes from identified gaps were used to revise the scenario.

The telehealth simulation was deployed to students during the week reserved for final exams during the Spring 2020 semester. Students were provided information that the patient was a 39-year-old married female recovering after a biopsy for Stage III breast cancer who had been referred for genetic counseling and risk assessment. The patient had one living child and one child who had died at age six after suffering two different forms of cancer. Students also received a visual copy of the patient’s pedigree. Objectives for the scenario included applying interviewing and counseling skills, demonstrating patient contracting, using education with anticipatory guidance for relevant genetic syndromes and risk communication, facilitating non-coercive decision-making, and reflecting on the experience. The students received instructions on how to schedule and record their individual SP experiences utilizing the Zoom conferencing platform.

Each student initiated the simulated telehealth simulation with the Standardized Patient and had 40 minutes to complete the scenario. Each student received verbal feedback about the experience from the SP immediately after the simulation was concluded. The SP also provided a written feedback summary to each student which was delivered via email. A faculty member reviewed each recording and scheduled feedback session with each individual student within a week of the scenario’s conclusion.

All students participated in one of two small group debrief sessions (six students per session) conducted over the Zoom conferencing platform. The research team member with simulation experience and training facilitated the debriefing using a method based on Tanner’s Model of Clinical Judgement (2006).

Data Collection

The sample included all 12 students currently enrolled in the Masters of Genetic Counseling program at Boise State university (N = 12). After the final debrief session, students were sent a survey about the telehealth simulation experience via a survey software platform (Qualtrics). The survey contained 12 Likert-type questions from the Simulation Design Scale (National League for Nursing [NLN], 2006) as well as three open-ended questions about the objectives, problem solving opportunities and fidelity of the simulation. Three additional questions asked what the most and least beneficial aspects of the simulation were and how it might or might not prepare a participant for the Genetic Counseling profession. This project received an exemption for educational research by the Boise State University Institutional Review Board.

Data Analysis

The Likert-type questions were analyzed by computing a mean score for each question. Open-ended questions were reviewed by the team for themes.

Results

Eleven of the 12 students completed the survey (n =11). The mean scores on the Likert type questions ranged from 3.9 to 4.9 on a 1 to 5 scale with one being strongly disagree and 5 being strongly agree (See table 1 at the end of the document). Students rated the question “I was encouraged to explore all the possibilities of the simulation” the lowest with a 3.9 and the question “Real life factors, situations, and variables were built into the simulation” the highest with a 4.9.

For the open-ended questions, the three themes that emerged were scheduling/technical details, anxiety, and usefulness.

Under the theme of details, the participants indicated that the simulation was scheduled during a busy end of the semester when other assignments were also due. Some also indicated that technical issues such as internet connectivity were a minor problem.

Several participants indicated they experienced heightened anxiety in response to the simulation. Some expressed that having a “stranger” (the simulation expert) lead the debriefing sessions was stressful. Others indicated that the time allotted for the simulation seemed too short. Some also expressed that the simulation was “high stakes” in nature although this was not the communication or the intent expressed by the faculty before or after the simulation.

In the third theme, students expressed that the simulation was useful to their learning. Direct feedback from the SP was identified as valuable as well as the opportunity to practice counseling with a “complete stranger.”

Conclusions

Faculty were satisfied with the intervention and the results. The program will continue to utilize this intervention with some minor modifications and may add a second telehealth simulation intervention as funding allows. The scores to the Likert type questions indicate that the design is strong. The lowest scored question, “I was encouraged to explore all the possibilities of the simulation,” was interpreted to reflect the 40-minute time limit that was imposed on the counseling session. Although in practice, this may be a reasonable amount of time for an experienced professional to complete a session, students with little experience may need either more time or fewer objectives to meet.

Faculty also considered how the timing of the intervention during finals week may have also contributed to student anxiety about the activity and the perception that it was a “final exam” or high stakes activity. The intervention was not intended to be a high stakes activity, but was required as a part of participation in the course. In the future, faculty indicated they would emphasize that the telehealth simulation was an opportunity for student practice.

Finally, in the third theme, faculty were pleased to find that the simulation scored very highly to both the Likert type question “Real life factors, situations, and variables were built into the simulation” and open-ended questions about the preparation it provided for future field training activity. In summary one student said “This exercise taught me more than any other assignment I’ve done in this program.”

Implications

It was only by chance that this research project coincided with the COVID-19 pandemic. Although the planning and pilot activity for this simulation project began in the Fall of 2019, the actual intervention and data collection occurred during a time that genetic counseling programs across the nation were attempting to transition to online education due to the pandemic. Program directors from traditional face-to-face programs across several states contacted the Boise State program leadership to learn more about delivering online synchronous telehealth simulations. A webinar was conducted with more than 150 attendees so that best practices for training of standardized patients and developing simulations could be addressed.

The research team planned a follow up survey after student participants began field training activities in the summer of 2020, however, due to the pandemic most students did not start field training during the expected timeframe. The follow up survey was intended to identify any changes in student responses after gaining some early experience with real patients. Even without the follow up survey, faculty found the telehealth simulation a useful activity to prepare students and also a way to observe if students were meeting program milestones.

Limitations

This educational research study included a small sample size and represented only one Masters of Genetic Counseling program, therefore, results may not be generalizable to all genetic counseling education programs. Additionally, researchers were unable to compare pre and post survey results as originally planned due to limitations imposed by the COVID 19 pandemic.

Means and standard deviations for Simulation Design Scale Likert type questions (1 = Strongly disagree, 5 = Strongly agree)

References

Holt, R. L., Tofil, N. M., Hurst C., Youngblood, A. Q., Peterson, D. T., Zinkan, J. L., Zinkan, J.L., White, M.L., Clemons, J.L., Robin, N. H. (2013). Utilizing high-fidelity crucial conversation simulation in genetic counseling training. American Journal of Medical Genetics Part A, 161A(6), 1273-1277.

International Nursing Association for Clinical Simulations and Learning Standards Committee. (2016, December). INACSL Standards of Best Practice: SimulationSM Participant Evaluation. Clinical Simulation in Nursing, 12, S5-S50. https://doi.org/10.1016/j.ecns.2016.09.009.

National League for Nursing. (2006). Simulation Design Scale.

National Society of Genetic Counselors. (2020). Professional Status Survey Reports. https://www.nsgc.org/p/cm/ld/fid=68.

Tanner, C.A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211.