Developing an integrated educational simulation ...

European Journal for Person Centered Healthcare 2017 Vol 5 Issue 1 pp 154-165

ARTICLE

Developing an integrated educational simulation model by considering art approach: Teaching Empathic Communication Skills AfsanehYakhforoshhaa, Seyed Amir Hossein Emami MDb, Navid Mohammadi MPH MDc, Mohammadali Cheraghi PhDd, Rita Mojtahedzadeh MPH MD PhDe, Behrooz Mahmoodi Bakhtiari PhDf and Mandana Shirazi PhDg a PhD Candidate, Medical School, Tehran University of Medical Sciences, Tehran, Iran b Associate Professor & Dean of Faculty of Medicine, Department of Medical Education, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran c Dean of Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran d Associate Professor, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran e Assistant Professor, Virtual School, Tehran University of Medical Sciences, Tehran, Iran f Associate Professor, Department of Performing Arts, University of Tehran, Tehran, Iran. g Associate Professor, Educational Development Centre (EDC), Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran & Senior Researcher, Science & Education Department, Södersjukhuset, Karolinska Institutet, Sweden

Abstract Introduction: Simulation plays an important role in integrated learning of communication skills. Communication skills are known as the heart and art of medicine. Although, designing high-impact learning experiences in simulated environments are essential elements in the process of communication training, it has encountered some challenges. Art-based education by providing ‘simulation’ of the wider experience of life as well as making creative thinking in medical students can help to overcome these issues. This article aims to develop a new model of simulation for communication skills education, the Integrated Model for Communication Skills (IMCS), by integrating the essential features of simulation and art. Materials and Methods: A review was done on the current literature of medical education, simulation model and main framework of art approach. Then, an expert panel by the use of nominal group technique (NGT) was held with medical education experts in Iran and Sweden to design, select an appropriate simulation model and approve the final model (IMCS) following some modifications. Results: IMCS is an integrated model in 3 concepts of Jeffries simulation model based on art approaches: simulation design, simulation intervention and outcome. The model used activity theory and transformative learning theory to foster outcomes of skill-based and emotional-based communication skills. Conclusion: Arts strategies could be incorporated into the simulation model. The IMCS has the potential to promote emotional and technical aspects of communication skills to make the healthcare providers as competent communicators. Keywords Art, communication skill, educational model, person-centered healthcare, simulation Correspondence address Dr. Mandana Shirazi, Department of Medical Education, Tehran University of Medical Science, Tehran, Iran. E-mail: [email protected], [email protected]. Accepted for publication: 5 January 2017

Introduction

posture, facial expression, expressive touch, body language and their so called paralinguistics. Such awareness and skills are also necessary to assess and respond to patients’ non-verbal cues in their communication behavior [1,2], professionalism, the ability to break bad news sensitively and with compassion and are vital in supporting patients and their families during crises [3]. Communication skills are regarded as one of the six core competencies recommended by the Accreditation Council

Communication skills are increasingly recognised as being at the heart of medicine and part of its art. Indeed, effective communication, both verbal and non-verbal, is fundamental for creating a therapeutic doctor-patient relationship. In this interaction doctors need to be continuously aware of their eye contact, body gesture and 154

European Journal for Person Centered Healthcare 2017 Volume 5 Issue 1

for Graduate Medical Education [4]. The importance of teaching and assessing communication skill has been recognized by expert bodies, both national and international, such as the Institute for International Medical Education (IIME), the Liaison Committee on Medical Education (LCME), the American Association of Medical Colleges (AAMC), the General Medical Council (GMC) of the UK and the Committee on Accreditation of Canadian Medical Schools (CACMS) [5]. Following the recommendations of international bodies, training of communication skills has been incorporated into many medical curricula [6] and this has resulted in various forms of educational methods to teach such skills within different institutions (i.e., role modeling as part of the ‘hidden curriculum’ and several experimental approaches such as role playing and patient simulation) [7]. In spite of the educational interventions that appear to be associated with improving physicians’ communication behaviors [8], there is no unequivocal evidence to demonstrate that transferring these skills from university to the workplace results in improved health and patient outcomes. Patients have reported that many of their supportive care needs remain unmet during encounters with their physicians [6,9]. To understand this one might consider the influence of the different perspectives among those who teach communication skills. For example, some educators pay more attention to skills-based or communication-based tasks. This reflects a reductionist paradigm [10]. "Reductionist thinking", atomizing complex behavior into its basic components, is widespread in medical education. This approach to teaching may be useful at an early stage of learning, but may limit the coherence needed to ensure that doctors communicate satisfactorily with their patients [11]. Moreover, patients’ views within clinical settings can diverge from those of experts. They focus much more on humanistic relationship and empathic communication [12]. In response to this challenge, integrated methods of teaching have been developed to cultivate both technical (skill-based) and non-technical (compassion-based) aspects of communication skills [13,14]. While standardized or simulated patient (SP) approaches play an important role in integrated learning of communication skills [13], there are clear limitations in using this modality within medical education. First and foremost, in a systematic review that was reported in 2014, limited evidence for the application of this method for teaching communication competency was reported [15]. Also, in the cost-effectiveness analysis, the evidence indicated that SP is an expensive tool for training communication skills [16]. Last but not least, a “one-size-fits-all” clinical scenario in teaching clinicianpatient communication is far from available. In the educational process, flexibility and improvisation for shifting from standardized patient to care actor should be integrated [17]. Furthermore, scientists such as Kneebone [18] advocate a new definition of simulation as a bridge between the closed world of simulation and wider context of real world clinical practice to enable real progress, compared two contrasting professional domains; emergency surgery (specific performance) and jazz improvisation (wider context of other performance). He

concludes that for achieving an effective performance in simulation-based education, it may be possible to invite experts from arts disciplines in order to assist the progress of medical education [18]. According to the literature, use of the creative arts in medical education can “open up” learners’ viewpoints and perceptions in order to encourage them to explore an understanding of patients’ perspectives, feelings and experiences as well as those of their families [19]. Use of arts-based approaches as novel educational perspectives in medical education may be categorized as follows: •

Literature: metaphors, writing poetry, novels, written narrative

•

Visual arts: painting, sculpture as well as the use of images, symbols

•

Performing arts: theatre, producing movies, operas and other vocal music [20].

The literature to date has shown that capacities for selfreflective, self-awareness and sensitivity to other’s needs which related to the mindful-base of communication are prerequisites for improving communication skills [21], although mindfulness skills in medical students can be promoted by using a variety of new arts-based approaches, such as painting, writing stories, theatre, visual journaling, poetry and visits to museums [22]. Arts-based education is thought to be complementary to two approaches in the teaching of communication skills: communication behaviors and mindful communication [23]. In addition, two main theoretical arguments support the contention that the arts can help medical students to become doctors with good communication skills: firstly, arts-based education, by providing a ‘simulation’ of the wider experience of real life, has the potential to create exciting opportunities for students to interact with other human beings that might otherwise remain unavailable; secondly, direct involvement in the arts-based process may assist medical students to reflect on their own feelings, critique them and foster innovative thinking [24]. Chen [25] is clear that simulation settings for the teaching of communication skills should change their direction from an objective and techniques base towards a more empathic approach. Teaching empathic communication requires more than providing a list of ‘dos and don’ts’ in the simulation setting. Empathic communication can be greatly enhanced by artsbased programs. For example, Eisenberg et al. [26] developed a technique termed ‘Facilitated Simulation Education and Evaluation (FSEE)’ based on lessons learned from theatre arts education in order to improve empathic communication [26]. There is now strong evidence that clinical communication can be effectively taught by integration into routine clinical practice of artsbased and simulation tools [27]. However, several medical schools integrate arts-based approaches into their medical curricula for developing students’ communication skills [10,28-32]. While several studies have been performed to integrate arts-based approaches with medical education in 155

Yakhforoshha, Emami, Mohammadi, Cheraghi, Mojtahedzadeh, Bakhtiari & Shirazi.

Developing an integrated educational simulation model by considering an arts-based approach

Phase 2

simulation contexts, there is no universally accepted educational simulation model in this field [27,33-37]. The present study aimed to develop new simulation models in medical education that integrates essential features of communication skill.

Nominal group technique

Firstly, three expert panel meetings were constituted to critically appraise 7 simulation models based on Brathwaite’s criteria in order to select the appropriate simulation model for developing the draft of Integrated Models for Communication Skills (IMCS). The criteria for criticizing models included comprehensiveness of content, logical congruence, conceptual clarity and level of abstraction and utility [38]. Secondly, a similar process was conducted for integrating arts-based approaches into the simulation model and approved final model.

Materials and Methods In this preliminary study, the integrated model was developed through several steps. The study was conducted between December 2014 and January 2015. In the first step, a narrative- integrative review was conducted through studying the literature on current medical education simulation models and the main frameworks of an artsbased approach. Then, three expert panels, through the use of nominal group technique (NGT), were held using Iranian and Swedish experts to select the appropriate simulation model and to approve the final model following some modifications.

Results As both the literature review and the nominal group technique approach were employed in order to develop the IMCS, results will be organized into two parts.

Participants

(1) The literature review results

During the developing and confirmation phases of the integrated communication model, 16 faculty members who were judged expert in simulation and arts-based disciplines, from both Iran and Sweden participated. These colleagues had at least 5 years of experience in simulation, arts-based and non-technical skills training (such as communication) and were familiar with simulation and arts-based approaches. The following steps were performed in order to develop the Integrated Model for Communication Skills (IMCS).

Six models of simulation were critically appraised in order to determine which model was the most appropriate to guide the development of IMCS for a research study. The first model analyzed was based on Brathwaite’s criteria and was related to Jeffries which was initially published as the Nursing Education Simulation Framework (NESF) in order to design, implement and evaluate simulation-based education in 2005 [39]. This framework included 5 constructs: student, teacher, educational practices, simulation design characteristics and outcome in 3 spheres. An international expert panel consists of simulation and nursing education reviewed constructs of framework. As a result, its name was revised from ‘Nursing Education Simulation Framework (NESF)’ to the ‘National League for Nursing-Jeffries Simulation Framework (NLN-JSF)’ [40]. Based on the appraisal criteria, it was comprehensive in content, had a high level of abstraction, conceptual clarity and logical congruence as well as feasibility in a variety of healthcare settings. The philosophical foundations of the model are explicit so that simulation educators are able to use this model in order to design, implement and evaluate simulation sessions for providing effective simulation training. A substantial body of literature has cited this model with general approval in their works. As this model clearly demonstrates a functional interaction between teacher and student, as well as educational practices with the outcome, it appears to be suitable for outcome-based education. A systematic review of the literature studying the Jeffries Simulation Framework provides empirical support for its major components [41]. The next model is Kneebone’s teaching-learning model for simulated scenarios. Kneebone’s model addresses 4 key principles. These include: (a) gaining and retaining technical proficiency, (b) the place of expert

Phase 1 Literature review

We initially conducted a systematic search of the literature using combinations of keywords including ‘simulationbased learning’, ‘medicine educational model’, ‘simulation models’, ‘simulation framework’, ‘theoretical framework’, ‘art education’, ‘art framework’ and ‘art models’ on the following databases: The Education Resource Information Center (ERIC), MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Inclusion criteria were predefined as follows: (a) Model applicable for a variety of medical disciplines, (b) Model described simulation design, implementation and evaluation, (c) Published in the English language and (d) Historical perspectives on simulation model (models were developed during 1990-2015). The final simulation models consisted of Jeffries’s [39], Kneebone’s [42,43], Dieckmann [45], Campbell and Daley’s [46], Keskitalo, T. [47], Park, M. [48] & Aebersold, M. [49]. Some arts-based approaches were also found during this process which would be utilized in integration with selected simulation models after appraisal.

156


Table1 Assessing simulation models based on Brathwaite’s criteria

Name of model

Jeffries [39]

Comprehensiveness

 Depth Described construct adequately with high coherency between concepts  Breadth It can guide clinical practice, research, education and administration

Logical congruence

Conceptual clarity  Defined and depicted association or causality between concepts completely  Premises drawn from the model -Learning as information processing. -Learning is individual experiential

 Congruency between content and philosophical claim  Integrate or redefine all concepts by different perspectives consistently

- Learning is socialcultural

 Depth

Kneebone, R. & Nestel,D. [43]

 Defined and depicted association or causality between concepts completely

-Described construct moderately

 Premises upon the model

-High coherency between concepts

- Learning is repeated practice and regular reinforcement

 Breadth It can moderately guide clinical practice, research, education and administration

-Learning is tutor support -Learning takes place in a professional context

 Congruency between content and philosophical claim  Integrate or redefining all concepts by different perspectives consistently

Level of abstraction

Utility

Total value for this study

 Processes of construction with the model  Not limited to time and space

Feasible in a variety of healthcare settings

+++++

 Has high level of abstraction.

Processes of construction with the model not limited to time and space


++++


++++

Has high level of abstraction.

-The effect of emotion on learning  Defines and depicts the association or causality between concepts completely  Premises upon the model Dieckmann [45]

 Depth -Described construct adequately -Coherency between concepts  Breadth It can specifically guide clinical practice, research, education and administration

-Prior knowledge and skills and attitudes are required for simulation activity. -Knowing basic principles and ability to interpret each encounter are essential for simulation. - Social practices are linked within an organization. - Simulation has its own reality.

157

 Congruency between content and philosophical claim

 Integrate or redefining all concepts by different perspectives consistently

 Processes of construction with the model not limited to time and space




- Simulation experience is differ from clinical experience  Depict association or causality between concepts completely  Depth -Described construct adequately Daley & Campbell [46]


 Breadth Cannot guide clinical practice, research, education and administration completely

 Defines and depicts association or causality between concepts completely

 Congruency between content and philosophical claims

 Premises upon the model -Considering what the learner brings to learning Including - individual experiences, culture and the digital culture.

 Integrates or redefines all concepts via different perspectives consistently

Processes of construction with the model not limited to time and space


+++

Has high level of abstraction

 Defines and depicts association or causality between concepts completely  Depth FTL model Facilitating, Training and Learning Model [47]

-Described construct adequately -High coherency between concepts  Breadth It can guide clinical practice, research, education and administration

 Premises upon the model

 Congruency between content and philosophical claim

-Learning related to all actions that take into account a person as a whole (body, mind and spirit) -The role of cultural tools and artifacts in learning (technology and language)

 Integrates or redefines all concepts by different perspectives consistently

 Processes of construction with the model not limited to time and space  Has high level of abstraction

 Feasible in many settings anesthesia residents and third and fourthyear medical students

++++

 Has been tested empirically - VR and simulationbased learning environment

- Seen as active, lifelong, life wide and deep collaborative knowledge co-creation process  Defines and depicts association or causality between concepts moderately

Practice-based simulation model (PBSM) Park [48]

 Depth Described construct weekly moderate coherency between concepts  Breadth It cannot guide clinical practice, research, education and administration completely

-Identification of two assumption on which the model is built -Simulation ProblemBased Learning -Importance of critical thinking skills in learning -Role of pedagogy principles in learning

 Congruency between content and philosophical claim  Integrates or redefines all concepts by different perspectives consistently

 Processes of construction with the model not limited to time and space  Has high level of abstraction

Feasible in a variety of healthcare settings and levels such as undergraduate, postgraduate and clinical education

+++

 Defines and depicts association or causality between concepts. The Simulation Model for Improving

 Depth Described construct adequately

 Depicts association or causality between concepts completely

158

 Congruency between content and

 Processes of construction

Based on feasibility in a variety of

+++


Learner and Health Outcomes (SMILHO) [49]


 Premises built upon the model

 Breadth it can’t guide clinical practice, research, education and administration completely

-Engaging learner in experiential learning

philosophical claim

- Learning is transferring knowledge and skill to practice

 Integrates or redefines all concepts by different perspectives consistently

with the model not limited to time and space

healthcare settings


- Evidence-based learning -Using technology in learning

(2) Nominal group's results

assistance in task-based learning, (c) learning within a professional context and (d) affective learning [42-44]. The content of this model appears immediately moderate and has a high level of abstraction, conceptual clarity and logical congruence, as well as a multi-setting utility (Table 1). The model concentrates on offering evaluation criteria to assess effectiveness of simulation. As it has focused on back and forth processes between simulation and clinical experience, it seems to be far more appropriate for curriculum development. Dieckmann’s model outlined 7-phase simulation-based modules for a simulation-based course. These modules include: (a) setting introduction, (b) simulator briefing, (c) theory input, (d) scenario briefing, (e) simulation scenario, (f) debriefing and (g) ending. It is comprehensive in content, with logical congruence and conceptual clarity, as well as multi-setting utility. This model has focused on planning and organizing simulation courses [45]. Campbell and Daley’s model is likewise comprehensive in content and has high levels of abstraction, conceptual clarity and logical congruence with clinical utility. This particular model has focused on integrating simulation pedagogy with nursing curricula and program outcomes. It has 22 concepts and appears to be very complex [46]. The model advanced by Keskitalo has conceptual clarity, clinical utility and logical congruence. It mostly emphasizes emotional, critical, goal-oriented and individual characteristics. It retains the potential to be applicable in virtual reality and simulation-based learning environments [47]. Park and associates have developed a separate model for simulation as part of a practice-based simulation model. It shows conceptual clarity, clinical utility and logical congruence and concentrates on fostering specific skills [48]. The model of simulation proposed by Aebersold and Titler has been known as the ‘Simulation Model for Improving Learner and Health Outcomes (SMILHO)’ which is comprehensive in content, showing conceptual clarity and easy application in clinical practice and research. This model has considered both learner and health outcomes, although the logic of the internal structure of the model is not readily comprehended [49].

(A) Determining the appropriate simulation model

The expert panels, based on the 5 criteria mentioned above, selected “The National League for Nursing-Jeffries Simulation Framework (NLN-JSF)” as the appropriate draft for Integrated Model for Communication Skills (IMCS). This model describes 5 conceptual components in 3 spheres. These sub-concepts in the first sphere include: 1) Teacher (as facilitator), 2) Student (as participant), 3) Educational practices; in the second sphere: 4) Characteristics of simulation design (prebrief, simulation activity and a debriefing) and in the third sphere consists of 5) Outcomes. We judge this model as abstract yet comprehensive enough to provide direction in developing an integrated simulation model. It has considered simulation design, implementation and evaluation. Concept development in NLN-JSF model is a result of empirical and theoretical literature of nursing, medicine and other non-healthcare related disciplines. It has been tested in empirical studies [41]. Additionally, the selection of simulation models needs to be congruent with the purpose of simulation base activity [39]. Since our purpose in using the simulation model is to determine how to achieve learners’ communication skills competency, choosing a model that clearly identifies learning outcomes would be the most beneficial for the purposes of the present study.

159



(B) Designing Art+ NLN-JSF simulation model (Figure 1) Sphere One Simulation design Figure 1 Integrated Models for Communication Skills

Table 2 Designing an educational practice based on activity theory

Activity plan: What sort of activity do you want to plan? Who does the activity fit in with your scheme of work or longer term planning? Objective: What is the aim of activity? Why is this activity taking place? What skills and knowledge are needed to carry out this activity? Subject: Who is involved in carrying out this activity? Is the whole class going to do the same thing at the same time? Tools: What resources will be used to carry out this activity? Are these tools predetermined? Do the learners need support using these tools? Do they possess the necessary conceptual knowledge or tools? Rules: Are there any cultural/ social/ political rules governing this activity? How can difficulties posed by these rules be overcome? Division of labour: How will you organize roles in the activity? Will everyone do the same thing? Who will do what and why? Community: How will roles be supported? In what sort of environment will this activity take place? How can the community be supported/ how does the art room/ learning environment act as a support mechanism? Outcome: What is the desired outcome of the activity? How will learners know they have reached the desired outcome? What sort of feedback will be offered to the learner?

The authors employed activity theory as the theoretical foundation for this section. This theory has the potential to

provide a common language for 3 fields of education including simulation, arts and communication [27,50,51]. 160


With regard to simulation-based learning, it deals with dynamic and complex environments and also supports social practice and engages multiple participants simultaneously. Therefore, instructional design should support theory that analyses mutually influencing relations between participants and the artifacts and tools as embedded in a complex dynamic simulation context [52]. Evidence indicates that activity theory should be employed in simulation education and can highlight the possibilities for learning to inspire change, innovation and the creation of new ideas [51]. In addition, employing activity theory is recommended for achieving professional practice in clinical communication skills among medical students. Furthermore, activity theory also guides instructors in an arts-based education [50]. This theory can be used for connecting between 2 separate organizational worlds in which the 2 parties together generate a new, shared objective(s) and concept for their shared activity [53]. By integrating arts-based approaches to simulation setting based on activity theory, learners can overcome the constraints on their actions in simulation settings by having access to the new ways of education in an arts-based setting. A connection between these 2 learning environments may suggest alternative forms of action for medical students by illustrating a new perspective on communication skills. Therefore, by applying components of activity theory [50] (Table 2), an integration between 2 parts of communication competency (skill-based, humanity-based) may occur. Thus, authors have utilized concepts of “multidisciplinary of educators”, instead of teacher, “multidisciplinary of participants” instead of learner and “multidisciplinary of practice” instead of educational practice.

on the analysis of 2 characteristics: (a) the degree of ambiguity or accuracy in delivery of inquiry and (b) the degree of learner participation. Based on those 2 features, a classification schema is made through employing 4 quadrants including: “Precise messages and passive strategies”, “Precise messages and active strategies”, “Ambiguous and active strategies”, “Ambiguous and passive strategies”. Examples of each strategy were presented in a matrix. Yet, in using these strategies, the influence of experience of learners, time, location and cultural issues should be considered. The model in which arts-based approaches is integrated with simulation activities will necessarily study the characteristics for educational practices such as “objectives”, “student support” and “problem solving” and was introduced by Jeffries [cf.39,40]. Another example of selection appropriate simulation modality has been published by Chiniara et al. [55]. They used the analysis of 2 characteristics including acuity (potential severity of an event) and opportunity (the frequency in which an individual is actively involved in the management of the event) to define a matrix. This matrix can be classified into 4 quadrants: high-acuity low-opportunity (HALO), highacuity high-opportunity (HAHO), low-acuity lowopportunity (LALO) and low-acuity high-opportunity (LAHO). Another characteristic that is important for designing educational practices in simulation activity is fidelity. It reflects the level of relationship between simulation and simulated system. “Surplus reality” involves using art as simulation. This expansion of experience was made by extensive use of ‘imagination’. Physical fidelity also can be achieved in an art-work approach through use of environmental attributes including the appearance and layout of the simulated setting. Finally, conceptual fidelity in an art-work approach can be made by offering interpretable information to the learner [56]. Debriefing is another attribute of educational practice in simulation experiences. It is a process whereby educators and students re-examine the clinical encounter and foster improvement in clinical reasoning and judgment skills through reflective learning processes. It is a crucial step in clarifying and consolidating insights and lessons from simulations [57]. Debriefing follows the art-work and is identified by the team analyses through a guided reflection of the participants upon the learning points. One example of this approach is Visual Thinking Strategies (VTS) with guided questions related to observation, interpretation and reflection. This strategy has the potential to engage students through discussion in order to increase observational, communication and critical thinking skills. In this strategy a trained facilitator engages small groups of students with the art-work [58]. In summary, different phases related to simulation intervention can also be employed within the different phases of psychodrama as a simulation setting:

Sphere two simulation intervention

The second sphere describes the implementation of a simulation intervention based on the first sphere’s information. In fact, sphere two acts as a simulation process that describes what happens before (the determination of educational goals), during (use of different simulation modalities) and after (debriefing) simulation activity. The emphasis of this section takes place with learners and their participation on learning. Therefore, authors apply arts-based knowledge translation strategies such as those addressed by Archibald [54]. This framework developed a base employing a transformative process, which is recommended for bridging the gap between theory and practice in communication training. In these approaches, the decision to use arts-based activity for participant engagement should be made based on the analysis of 2 characteristics: (a) the degree of ambiguity or accuracy in delivery of inquiry and (b) the degree of learner participation. Based on those two factors, a classification schema is made using 4 quadrants including: “Precise messages and passive strategies”, “Precise messages and active strategies”, “Ambiguous and active strategies”, “Ambiguous and passive strategies”. Some examples of each strategy were presented in a matrix. In these approaches, the decision to use arts-based activity for participant engagement should be made based

 Pre-briefing: receive information from participants before actually coming to the course  Setting an introduction: at the beginning 161



participants are enabled to get to know each other and what the setting is about

suited to multidisciplinary education. All seven models in our view meet conceptual clarity criteria. Jeffries’s [40] model has a simple, yet comprehensive approach. As a philosophical tenet, educational/learning theory that is subdirectory of conceptual clarity and level of abstraction was explicit in six of the seven models we studied [39,40,42-48]. With regard to the selected educational/learning theories underpinning them, all models used different theorists. The Aebersold’s model did not show criteria cited by others in an unequivocal manner. Each of the seven models has different levels of comprehensiveness of content. The concept description and guide for clinical practice varied in their level of detail across models when one considers the studies cited here. Due to feasibility differences in different healthcare settings, Jeffries’s model was one of the most frequently cited models in nursing and other healthcare educational research studies. The highest agreement between experts’ opinion in Iran and Sweden according to the criteria and purpose of the study was related to the Jeffries’s model of simulation. A focus on the two parts of communication skills as an ultimate outcome and use of performance arts-based simulation to facilitate complex communicative skills, induce thinking about designing IMCS as a relation between simulation-based education and art experiences. The IMCS shares some common key elements of simulation-based education with other art approaches that we have reviewed. However, the model that emerged from the data has a number of innovative aspects, particular for the Iranian medical educational context. Integration of the two approaches appears to be more comprehensive than merely a simulation setting. Some concepts from IMCS were convergent in Sweden and Iran such as concepts in sphere one (multidisciplinary approach) and sphere three (outcomes). However, some divergent concepts were also identified that include in part of educational activity based on Archibald et al. work in sphere two. They were containing dance as a learning activity in their classification schema. Although, there is evidence which shows that arts-based teaching and learning practices are particularly effective with learners from diverse cultures [60], the main concepts distinguish between Iranian and Swedish contexts in confirmation of IMCS derived in dance as a learning engagement that considered quadrant three of sphere two. This subject seems to be in agreement with opinion of Archibald et al. These authors demonstrated how context should be considered in development and implementation in arts-based intervention. Therefore, they contribute issues of context, time, or location in their flexible arts-based engagement strategies. Developing integration frameworks for simulation in healthcare education scenarios have been published previously within the global literature. But, the focus of these frameworks is advanced as different from what is reported here. They integrate various simulation modalities and models in virtual settings. Indeed, these frameworks aimed to improve the accessibility of simulation data and computational models for developing simulation

 Simulator briefing: A principal explanation of the simulator, its environment and how both can be used for training  Theory input: key concepts are explained (not given in all settings)  Breaks: relaxation phases  Scenario Briefing: An explanation about concrete scenario, the principle roles and task  Debriefing: A guided reflection in and on actions during the scenario and performance  Course Ending: Reflection of the participants upon the learning points at the end of the course [56]. Sphere three: outcome

Arts-based intervention provides an innovative mechanism for learners to increase a higher level of awareness and sensitivity to change. A combined educational model with an arts-based approach can facilitate learning through activity, creativity and play [58]. Creativity in clinical communication is the vital element for shifting the participant from communication skills in a theoretical context to the creation of skilled communicators in a real world clinical context. It encourages innovation, reflection, synthesis and evaluation [10]. Reports within the literature have noted that arts-based learning integrated with classical modern medical education helps learners to gain skills in critical thinking, creativity, collaboration and understanding of multiple perspectives that they could not otherwise access [59]. (C) Approval and dissemination final model Following the incorporation of some of the faculty members’ comments and making minor modifications for approving IMCS, the agreement between experts was higher than 90% and no further suggestions were made.

Discussion This paper describes the process of developing IMCS following a literature review and the views of expert panels and thus nominal group technique. As a first step, the results of the analysis of simulation models within the context of criteria are presented here. This analysis was not performed to select one model in favour of over another, but to guide authors in selecting one model that was well 162


technically [54]. The IMCS model we present is focused solely on the integration of psychological and technical aspects of current educational simulation models in reallife clinical settings. An ongoing process using qualitative and literature review methods enables us to overcome some challenges of current integrated simulation frameworks. For instance, we have extended the simulation model with an arts strategy which is recognized as a promising trend in the current communication education derived from the existing literature. Additionally, we found that multidisciplinary participants involved in the development of an integrated model, defined concepts that are necessary for communication learning. Our experience was consistent with Grapczynski et al. that emphasizes the role of interprofessional faculty team participants as essential participants in defining combined concepts for the development of an integrated educational model [61]. The IMCS model can be considered as a powerful learning experience through combining simulation with an arts-based strategy. This model can provide diverse situations in order to synthesize communication competency for clinical practice via offering different contexts and modalities. While there has been a measure of virtual integrated educational models in the field of simulation-based education [62], real world clinical practice has failed explicitly to define specific eclectic simulation models for communication skills training. The proposed eclectic simulation model is a resource that learners continually travel alongside skill base and human base of communication competent in simulation setting learning. In this educational model, learners should also understand ‘that skill is essential, but not enough; the heart is equally important in order to developing understanding of others’ emotions’.

faculty development in arts-based methods should be provided. For the successful implementation of this model, students should achieve competency in such skills, including creativity, problem-solving, perseverance and collaboration.

Conflicts of Interest The authors report no conflicts of interest

References [1] Khan, F.H., Hanif, R., Tabassum, R., Qidwai, W. & Nanji, K. (2014). Patient attitudes towards physician nonverbal behaviors during consultancy: result from a developing country. ISRN Family Medicine doi: 10.1155/2014/473654. [2] Silverman, J. & Kinnersley, P. (2010). Doctors' nonverbal behaviour in consultations: look at the patient before you look at the computer. British Journal of General Practice 60 (571) 76-78. [3] Baile, W.F. & Blatner, A. (2014). Teaching communication skills: using action methods to enhance role-play in problem-based learning. Simulation in Healthcare 9 (4) 220-227. [4] Lurie, S.J., Mooney, C.J. & Lyness, J.M. (2009). Measurement of the general competencies of the accreditation council for graduate medical education: a systematic review. Academic Medicine 84 (3) 301-309. [5] Rider, E.A., Hinrichs, M.M. & Lown, B.A. (2006). A model for communication skills assessment across the undergraduate curriculum. Medical Teacher 28 (5) e127e134. [6] van den Eertwegh, V., van Dalen, J., van Dulmen, S., van der Vieuten, C. & Scherpbier, A. (2014). Residents' perceived barriers to communication skills learning: comparing two medical working contexts in postgraduate training. Patient Education and Counseling 95 (1) 91-97. [7] Shield, R.R., Tong, I., Tomas, M. & Besdine, R.W. (2011). Teaching communication and compassionate care skills: an innovative curriculum for pre-clerkship medical students. Medical Teacher 33 (8) e408-e416. [8] Rao, J.K., Anderson, L.A., Inui, T.S. & Frankel, R.M. (2007). Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Medical Care 45 (4) 340-349. [9] Oliveira, V.C., Ferreira, M.L., Pinto, R.Z., Filho, R.F., Refshauge, K. & Ferreira, P.H. (2015). Effectiveness of Training Clinicians' Communication Skills on Patients' Clinical Outcomes: A Systematic Review. Journal of Manipulative Physiological Therapeutics 38 (8) 601-616. [10] Salmon, P. & Young, B. (2011). Creativity in clinical communication: from communication skills to skilled communication. Medical Education 45 (3) 217-226. [11] Kidd, J., Patel, V., Peile, E. & Carter, Y. (2005). Clinical and communication skills. British Medical Journal 330, 374-375.

Conclusion The integrated simulation model has several advantages for both trainer and trainee. First, it promotes communication skills for learners by developing real and latent skills (human aspect) interactively. The arts-based approach provides forms of non-verbal communication that are close to language. Second, it provides an experiential framework which is the most effective way for teaching this skill. Third, the model offers opportunities for multidisciplinary education. Consequently, different perspectives and contexts enrich the application of knowledge to new problems and enable new skills to be practised in multiple contexts. The literature shows that applying arts as a performance-based simulation model can enhance some clinical skills in a shorter time and in a more cost-effective and efficient way [63]. We should consider that an arts-based approach does not just combine two disciplines, but rather it is a teaching approach that aims to improve the level of learning for both disciplines. The main challenges of the new educational model involves implementation issues that correlate with some difficulty. For example, strong support from academic administrators will be necessary. Moreover,

163



[12] Ha, J.F. & Longnecker, N. (2010). Doctor-patient communication: a review. Ochsner Journal 10 (1) 38-43. [13] Moulton, C-A., Tabak, D., Kneebone, R., Nestel, D., MacRae, H. & LeBlanc, V.R. (2009). Teaching communication skills using the integrated procedural performance instrument (IPPI): A randomized controlled trial. The American Journal of Surgery 197 (1) 113-118. [14] Zoppi, K. & Epstein, R.M. (2002). Is Communication a Skill? Communication Behaviors and Being in Relation. Family Medicine 34 (5) 319-324. [15] Shirazi, M., Mohammadikia, A. & Jahanian, I. (2015). A Systematic Review of Studies Regarding Applying Standardized Patients for Teaching Communication Skills to Medical Students Between 2000 - 2013. Journal of Medical Education 10 (2) 150-162. [16] Bosse, H.M., Nickel, M., Huwendiek, S.R, Schultz, J.H. & Nikendei, C. (2015). Cost-effectiveness of peer role play and standardized patients in undergraduate communication training. BMC Medical Education 15 (1) 183. [17] Hardee, J.T. & Kasper, I.K. (2005). From standardized patient to care actor: evolution of a teaching methodology. The Permanente Journal 9 (3) 79-82. [18] Kneebone, R. (2011). The art, science and simulation of performance. Proceedings of the International Symposium on Performance Science. [19] Kumagai, A.K. (2012). Perspective: acts of interpretation: a philosophical approach to using creative arts in medical education. Academic Medicine 87 (8) 11381144. [20] Weisz, G. & Albury, W. (2010). The medico-artistic phenomenon and its implications for medical education. Medical Hypotheses 74 (1) 169-173. [21] Choudhary, A. & Gupta, V. (2015). Teaching communications skills to medical students: Introducing the fine art of medical practice. International Journal of Applied Basic Medical Research 5 (Supplement 1) S41. [22] Potash, J.S., Chen, J.Y., Lam, C.L. & Chau, V.T. (2014). Art-making in a family medicine clerkship: how does it affect medical student empathy? BMC Medical Education 14, 247. [23] Perrona, N.J., Sommerc, J., Louis-Simonetd, M. & Nendaz, M. (2015). Teaching communication skills: beyond wishful thinking. Swiss Medical Weekly 145, w14064. [24] Perry, M., Maffulli, N., Willson, S. & Morrissey, D. (2011). The effectiveness of arts-based interventions in medical education: a literature review. Medical Education 45 (2) 141-148. [25] Chen, R.P. (2011). Moral imagination in simulationbased communication skills training. Nursing Ethics 18 (1) 102-111. [26] Eisenberg, A., Rosenthal, S. & Schlussel, Y.R. (2015). Medicine as a Performing Art: What We Can Learn About Empathic Communication From Theater Arts. Academic Medicine 90 (3) 272-276. [27] Brown, J. (2010). Transferring clinical communication skills from the classroom to the clinical environment: perceptions of a group of medical students in

the United Kingdom. Academic Medicine 85 (6) 10521059. [28] Jeffrey, E.J., Goddard, J. & Jeffrey, D. (2012). Performance and palliative care: a drama module for medical students. Medical Humanities 38 (2) 110-114. [29] Kumagai, A.K. (2012). Perspective: acts of interpretation: a philosophical approach to using creative arts in medical education. Academic Medicine 87 (8) 11381144. [30] Staricoff, R.L. (2006). Arts in health: the value of evaluation. Journal of the Royal Society for the Promotion of Health 126 (3) 116-120. [31] Watson, K. (2011). Perspective: Serious play: teaching medical skills with improvisational theater techniques. Academic Medicine 86 (10) 1260-1265. [32] Younie, L. (2013). Introducing arts-based inquiry into medical education: ‘exploring the creative arts in health and illness’. Creativity in the Classroom: Case Studies in Using the Arts in Teaching and Learning in Higher Education, pp.23-40. Bristol: Intellect Books. [33] Bachmann, C., Barzel, A., Roschlaub, S., Ehrhardt, M. & Scherer, M. (2013). Can a brief two-hour interdisciplinary communication skills training be successful in undergraduate medical education? Patient Education and Counseling 93 (2) 298-305. [34] Bell, B.S., Kanar, A.M. & Kozlowski, S.W. (2008). Current issues and future directions in simulation-based training. CAHRS Working Paper Series 492. [35] Bennett, K. & Lyons, Z. (2011). Communication skills in medical education: an integrated approach. Education Research and Perspectives 38 (2) 45. [36] Lanning, S.K., Ranson, S.L. & Willett, R.M. (2008). Communication skills instruction utilizing interdisciplinary peer teachers: program development and student perceptions. Journal of Dental Education 72 (2) 172-182. [37] Smith, J.R. & Cole, F.S. (2009). Patient safety: effective interdisciplinary teamwork through simulation and debriefing in the neonatal ICU. Critical Care Nursing Clinics of North America 21 (2) 163-179. [38] Brathwaite, A.C. (2003). Selection of a conceptual model/framework for guiding research interventions. Internet Journal of Advanced Nursing Practice 6 (1) 1-10. [39] Jeffries, P.R. (2005). A framework for designing, implementing, and evaluating: Simulations used as teaching strategies in nursing. Nursing Education Perspectives 26 (2) 96-103. [40] Jeffries, P.R. (2012). Simulation in nursing education: From conceptualization to evaluation National League for Nursing. New York. [41] Adamson, K. (2015). A Systematic review of the Literature related to the NLN/Jeffries Simulation framework. Nursing Education Perspectives 36 (5) 281291. [42] Kneebone, R. (2005). Evaluating clinical simulations for learning procedural skills: a theory-based approach. Academic Medicine 80 (6) 549-553. [43] Kneebone, R. & Nestel, D. (2005). Learning clinical skills-the place of simulation and feedback. The Clinical Teacher 2 (2) 86-90.

164


[60] Rooney, R. (2004). Arts-Based Teaching and Learning; a review of literatre 2004. Prepared for:VSA ARTS, Washington, DC. Retrieved from: http://www.kennedycenter.org/education/vsa/resources/VSAarts_Lit_Rev528.pdf. [61] Grapczynski, C.A., Schuurman, S., Booth, A.D., Bambini, D. & Beel-Bates, C. (2015). The Integrated Model for Interprofessional Education: A Design for Preparing Health Professions' Students to Work in Interprofessional Teams. Journal of Allied Health 44 (2) 108-114. [62] Kononowicz, A.A., Narracott, A.J., Manini, S., Bayley, M.J., Lawford, P.V., McCormack, K. & Zary, N. (2014). A framework for different levels of integration of computational models into web-based virtual patients. Journal of Medical Internet Research 16 (1) e23. [63] Cowan University PWA. (2008). Bridging the Theory to Practice Gap Using Performance Based Simulation. Edu-Com International Conference. Western Australia in association with Khon Kaen University, Thailand and Bansomdejchaopraya Rajabhat University, Thailand.

[44] Kneebone, R., Scott, W., Darzi, A. & Horrocks, M. (2004). Simulation and clinical practice: strengthening the relationship. Medical Education 38 (10) 1095-1102. [45] Dieckmann, P. (2009). Using simulation for education, training and research. Lengerich, Germany: Pabst Science. [46] Campbell, S. & Daley, K. (2009). Simulation scenarios for nurse educators: Making it real. New York: Springer Publishing Company. [47] Keskitalo, T., Ruokamo, H. & Väisänen, O. (2010). How does the facilitating, training and learning model support characteristics of meaningful learning in a simulation-based learning environment from facilitators’ and students’ perspectives. Proceedings of world conference on educational multimedia, hypermedia and telecommunications. AACE Chesapeake, VA. [48] Park, M., McMillan, M., Conway, J., Cleary, S., Murphy, L. & Griffiths, S.K. (2013). Practice-based simulation model: a curriculum innovation to enhance the critical thinking skills of nursing students. Australian Journal of Advanced Nursing 30 (3) 41-51. [49] Aebersold, M. & Titler, M.G. (2014). A simulation model for improving learner and health outcomes. Nursing Clinics of North America 49 (3) 431-439. [50] Addison, N. & Burges, L. (2008). Learning to Teach Art and Design in the Secondary School. Second edn: Taylor & Francis e-Library. [51] Berragan, E. 2013. Conceptualising learning through simulation: Towards an expansive model of learning. Belfast: RCN International Research Society Conference. [52] Battista, A. (2015). Activity Theory and Analyzing Learning in Simulations. Simulation & Gaming 46 (2) 187196. [53] Frambach, J.M., Driessen, E.W., van der Vleuten, C.P. (2014). Using activity theory to study cultural complexity in medical education. Perspectives on Medical Education 3 (3) 190-203. [54] Archibald, M.M., Caine, V. & Scott, S.D. (2014). The Development of a Classification Schema for Arts-Based Approaches to Knowledge Translation. Worldviews on Evidence-Based Nursing 11 (5) 316-324. [55] Chiniara, G., Cole, G., Brisbin, K., Huffman, D., Cragg, B., Lamacchia, M., Norman, D. & Canadian Network for Simulation In Healthcare. Guidelines Working Group. (2013). Simulation in healthcare: a taxonomy and a conceptual framework for instructional design and media selection. Medical Teacher 35 (8) e1380e1395. [56] Poikela, E. & Poikela, P. (2012). Towards simulation pedagogy Developing Nursing Simulation in a European Network: Rovaniemi University of Applied Sciences Publications. [57] Chesak, S. (2010). The essentials of debriefing in simulation learning: a concept analysis. Nursing Education Perspectives 31 (1) 46. [58] Moorman, M. (2015). The meaning of visual thinking strategies for nursing students. Humanities 4 (4) 748-759. [59] Riggins, E.C. (2014). Integrating the Arts and Sciences in the Museum Setting. Seton Hall University Dissertations and Theses.

165