Human Simulation Beyond Healthcare: Experience, Reputation, and Relationship Building

Abstract

In this chapter we describe our experiences of developing human simulation projects across an expanded professional education landscape as seasoned simulated patient educators informed by different backgrounds and institutional knowledge. The power of human simulation is increasingly recognized by professionals who work in fields outside of the health professions that include law, architecture, chaplaincy, law enforcement, business, the military and human resources. We detail several educational activities that we have designed and delivered over the years and share our perspectives about ingredients essential for carrying out successful projects with clients new to human simulation. In addition to the project-specific details we share, we find the most essential ingredients for successful simulation work beyond healthcare fields with new clients include experience, reputation, and relationship building.

Appendix 13.1

Simulated Service Member – Michaela Lowry

Date(s) and content revised: Carol Stewart 7/3/17, Tiffany Garfinkle 7/26/17, Joseph Grammer 11/15/17

Case template-Military Chaplain Simulation Event created by Lou Clark, MFA, PhD & Tiffany Garfinkle, MA

Case author and date written: Lou Clark, MFA, PhD, Tiffany Garfinkle, MA, Joseph Grammer, Michael Montgomery, BS, A. Graham Sterling IV, PhD, Carol Stewart, MSW, NCC, and Stephanie Phalen, SP who pilot tested and originated this role.

Goals for learner:

• 1. Emotion Regulation

Case objective(s) for learner:

• 1. Explain the role of emotion dysregulation in elevating suicide risk.

• 2. Summarize adaptive and maladaptive functions of emotions.

• 3. Discuss the connections among thoughts, emotions, bodily sensations, and behaviors.

• 4. Assist in the identification of emotions (expansion of emotional vocabulary) and rating of their intensity on a continuum.

• 5. Introduce at least two strategies for emotion regulation to prevent future suicidal crises.

Opening statement: “There’s something I need to tell you, but I’m not sure how…”

Service member demographics:

• Age range: 35–45

• Gender: Female

• Ethnicity: Caucasian

• Location: Chaplain’s office at Joint Expeditionary Base Little Creek (Portsmouth Medical Center)

Service member clothing: Civilian attire

Is there a gown required during encounter? No

Is there a door sign with this case? Yes, chaplain pre-encounter

Chaplain Information

Service Member Information

• Name: Lieutenant Commander Michaela Lowry

• Setting: Chaplain’s office at Naval Medical Center Portsmouth (NMCP)

Lieutenant Commander Michaela Lowry is the head of the Endocrinology/Diabetes Clinic at NMCP. She was raised as a Presbyterian and she attends Christian services when she has time (about every 1–2 months—you know her casually because of this). She called and made this appointment with your RP, and the RP told you she sounded pretty upset.

Learner Instructions

Goals for learner:

• 1. Emotion Regulation

Tasks:

• 1. Explain the role of emotion dysregulation in elevating suicide risk.

• 2. Summarize adaptive and maladaptive functions of emotions.

• 3. Discuss the connections among thoughts, emotions, bodily sensations, and behaviors.

• 4. Assist in the identification of emotions (expansion of emotional vocabulary) and rating of their intensity on a continuum.

• 5. Introduce at least two strategies for emotion regulation to prevent future suicidal crises.

Time Limit: 30 Minutes

SP Educator/Trainer Notes – Michaela Lowry

• Trainers: Tiffany Garfinkle

• Date: August 2017

• Activity: Chaplain Event

Describe any changes in or clarification to case details and why:

If your suicide story has not come out by 10 minutes into the encounter, say something to encourage the chaplain to ask you about it. (“I just don’t know how much longer I can go on like this” – just an example)

Describe any changes in the door sign:

Describe adjustments or changes in SP portrayal (e.g. affect, verbal or non-verbal cues):

Describe changes in information/responses given by SPs (e.g. ways of answering open- and close-ended questions):

Service Members refer to chaplains as “Chaps.” Use this or “Sir/Mam” (what you feel is appropriate for your character). Chaplains will most likely tell you to use their first name if you start to call them sir/mam.

If asked if you would like to pray with the Chaplain: If you feel it is appropriate for your character, you can say “yes.” If the Chaplain asks you to take the lead on this you can say, “I’d like to pray silently alongside of you.”

Chaplains are known for giving relationship advice.

At the end of the encounter, the chaplain might mention you waiting in the room with his “RP”. An RP is a religious program specialist. A Religious Program Specialist (abbreviated as RP) is a United States Navy rating. Religious Program Specialists assist Navy chaplains. Religious program specialists provide support to Navy chaplains in developing programs to meet the needs of Navy and Marine Corps personnel and their families. RPs perform functions that do not require ordination and do no pastoral counseling. They also protect the chaplain on deployment.

For your information: The chaplains could use the following terms, especially if your character has been deployed or is on deployment:

Garrison – collective term for a body of troops stationed in a particular location, originally to guard it, but now often simply using it as a home base. The garrison is usually in a city, town, fort, castle, etc.

Inside the wire – within the confines of a camp/base/forward operation base.

Outside the wire – military jargon for being beyond the relatively safe confines of a base camp or support installation

Describe any new training tools/aids/techniques used (e.g. relevant Mind Map, timelines, previous encounters reviewed):

General instructions to guide the SP:

Suicide Ideation

Active suicidal thoughts/ideation with a plan (pills)

Level of Emotion

Whatever what is most intense manifestation of your characters emotionality, allow that to take place at outset of encounter, but then allow emotions to gradually subside over the course of 30 minutes. Don’t go big or ramp up the emotionality in the last few minutes of the encounter, even if it could be in character or is appropriate. Stay in character, but subdued emotionality is desired at the end of the encounter.

Interventions

• 1. Emotion Regulation

Once you detect an intervention is taking place, be broadly receptive. If appropriate to your character, you can be wary initially for first minute or so of intervention, and you can gently push back during intervention if your character is uncomfortable. Overall, allow Chaplain to go through intervention.

Describe props and how used:

Describe any pressing issues for immediate or future changes (e.g. new questions to checklists):

Describe any problems/difficulties to bring to debrief/SPOT meeting for resolution (e.g. student issues from debrief, awkward case moments):

Service Member Training Notes

Note: If there are some lengthy quotes in this case. You do not need to know them verbatim. Use them for content.

Name:	Michaela Lowry
Clothing:	Civilian attire
Reason for visit:	Suicidal Ideation due to struggle with sexual identity
Opening Statement:	“There’s something I need to tell you, but I’m not sure how…”
Opening follow up:	“I’m just so overwhelmed, and I guess I’m having some sort of identity crisis…”
Trigger Question (question designed to interrupt chaplain if they are asking questions in mechanistic/wrote style):	“Will God love me if I’m gay?”
Reason for seeking Spiritual Counseling (note – this could be the same or different from “reason for visit” above. Meaning – this could be overt or covert):	Need to discuss struggle with sexuality and didn’t know where else to go. You attend Christian services occasionally (every 1–2 months) this is how you know this chaplain. You have met with various chaplains over many years to discuss spiritual issues. You came to see the chaplain today, because you have been struggling with this situation ever since it happened. You are very afraid this woman will out you, and your reputation will be ruined.
Social History:	Age: You are 43 years old. Family Background/Upbringing: You were raised in a loving, but conservative family. You grew up in Tulsa, Oklahoma and are an only child. Your parents were model citizens, pillars of the community. Dad was a church deacon. Mom was an officer in the rotary club. If asked: “I was a model kid. Straight A’s, varsity soccer, volunteering on weekends, and working part-time in the summer.” When you were in high school, you knew someone in your community who was outed as being gay when he confided in his friend. This led to church interventions and a great deal of shame for that family. After witnessing that, you dealt with your “impulses” by praying, but avoided addressing those feelings. Current Living Situation (i.e. spouse, children, friends, and pets): You own a home in Virginia Beach. You are single and live alone. You have a golden retriever named Admiral Byrd. You are very social and have many friends at your current duty station and from others around the world. You are considered affable, popular, witty, and hard working. In all respects, you are a model US Naval Officer and you are known for accepting full responsibility when something goes wrong. Dating has always been a struggle for you. In high school and college, you tried to date men. You had a few boyfriends who were “nice guys,” and you’re still friends with them. You just couldn’t allow yourself to be serious about them. At the time, you told your family that you wanted to focus on your dream of becoming a doctor. Once you were in medical school, you were too busy to date seriously, even though several of your classmates were dating and getting married. You continued being “too busy to date” through your residency. When you were named Chief Resident, you were really excited and wanted to give that “total focus.” After residency, you felt you had more time to yourself and began exploring feelings you denied – specifically your attractions to women – that went all the way back to your first experiences with puberty. Throughout your 30’s you had very brief relationships with women, none of whom were in the military. You have struggled since this time, because you have always believed homosexuality is a sin. This is causing internal conflict for you – you are happiest when dating women, but you simultaneously deal with the byproduct of self-loathing/self-hatred. On top of all of your own internal conflict, you are concerned that if you come out your parents won’t love you anymore, and that you won’t be accepted by your military colleagues and friends. Your parents, over the years, have sparked arguments with you about why you never married. Throughout your residency, they accepted that you were too career driven. Throughout the last 10 years, they have put on the pressure, especially as you are an only child. You are their one shot for grandchildren. Two weeks ago, you went to a party hosted by a mutual friend, another Presbyterian officer named Carlyle. You were having a great time, and one of the guests, a woman named Lisa, seemed to be paying a lot of attention to you. You thought you were getting signals from her that she was interested in you romantically. You hung around, with her encouragement, until the end of the party. You were the last one there. When you said goodnight, you asked Lisa if she wanted to get together sometime. She enthusiastically said, “Yes.” A week ago, the two of you went out to dinner together. You had what you thought was a great time. When you went to say goodnight, you walked her to her car and then got up the courage to ask if you could kiss her. Your date was very surprised and said “No, I don’t know what you were thinking, but I’m not that way!” She got in the car and sped off.
	If asked : “I just stood there. I was mortified.” (Note: The woman you went out with is not in the military and does not work at the hospital you work at. You are worried that you will be outed to your non-military friends. This would be a complete change of your identity.) Since your date, you have been throwing yourself into work – doing anything you can to take your mind off what happened. This has had a negative impact on you – you are exhausted and feel like you are at a breaking point. When you stopped to think about yesterday, you realized you felt worse now than you did on a stressful deployment. You have been thinking about taking your life since the date and for the past week, you have been taking out your bottle of Valium and pouring yourself a glass of water and contemplating taking the pills. You sit and stare at the pills and picture what happened over and over. Most of your friends are other officers in the clinic. You know they are “educated, nice, and pretty openminded,” but you are still afraid for them to know. Your closest friend is a fellow Lieutenant Commander and doctor named James Whitmore. James is from New York City and is “crazy liberal.” You often have friendly arguments with him, since you tend to be conservative in your views. He often jokes that he never sees you on dates. If asked if your friends would reject you if they knew you were a lesbian: “I don’t know … They act nice to me now, but who knows? Maybe they’ll be mad I lied. I don’t know.” If asked about your family: “My parents are getting older now (70s). They just think I’m a woman who loves her career and doesn’t have room for a man, and they made peace with that. I think coming out to them would break their hearts.” If the chaplain does a good job helping you regulate emotions: “Maybe James would understand and be OK, but I’m still not ready for anyone to know. Maybe never.” If asked: “I still know it’s a sin, at the end of the day. I don’t know what to do about that. I still pray.” Your emotions have varied wildly on the issue of people “knowing about you.” Sometimes you feel that your friends won’t care, but other times your shame about the” sinfulness” of being a lesbian comes back, and you’re terrified about what people will think. If asked: “I remember the days where you got kicked out if you were gay. I can’t just forget that.” If asked: “I have lots of friends, but they usually tell me their personal things, not the other way around. I don’t give my details out—they know I’m private.” If asked: “I’ve never told anyone I didn’t date. Not friends, not family. Some women I tried dating laughed at me, or said they felt sorry for me because I couldn’t be honest with myself. I don’t think they understood how things were for me.” If asked: “Most people in the clinic just care if you can do your job. We have one openly gay man who’s enlisted, Petty Officer Harrison, a medical tech. He seems like he’s OK with how people treat him, but still … how do I know what goes on in his life? Some people call him their ‘gay best friend,’ and he just laughs, but I would hate that. I don’t like how people fixate on the fact that someone’s gay and always bring it up.” You have several fears about this issue. One fear is that people will treat you differently if you’re outed, either like “I’m weird or exotic” or in a disapproving way. “Some people in my chain of command, especially my Captain, are pretty traditional, even more than me.” Another fear is that you will lose your privacy, and people will start asking you lots of questions about “what it’s like to be gay.” You’re also afraid about not being able to control whether or not you get to come out— “it all depends if Lisa told Commander Carlyle, and if he told someone else.” You’ve been so distraught that you’ve had suicidal thoughts since the date (2 weeks ago). One week ago, you even considered taking some old Valium pills leftover from an old back injury. Several times you have set the pills in front of you with a glass of water, “just to see if it helped,” but you haven’t taken any yet. You feel tremendous guilt about “who I am,” and when the feeling gets strong enough, you think it’s better to just kill yourself and “be done with this.” Note: the operative skill here we want to see the learners demonstrate is emotion regulation, not safety planning, so steer the chaplain away if they try to go the safety planning route. If asked: “I still feel like hurting myself sometimes, but I don’t want to. I believe suicide is a sin and I know it hurts people, and I don’t want to do it. Sometimes the feeling gets strong, though, and then it’s hard.” If the chaplain presses you about safety planning, you can say that you “flushed the pills yesterday” and don’t have any other weapons or medication at home. If asked when you felt most comfortable with your sexuality: “I dated one civilian woman named Selena for a few weeks, when I was maybe 35. She had some really good talks with me about how you can love God and follow Him but also still be yourself. She was raised Episcopalian and being gay was totally normal. She had a gay priest, even. I felt OK about myself then, but I still got afraid later and ended the relationship.”
	Religious Background: You were raised in an active Presbyterian environment. You believe in God, desire to go to heaven, and attend services when you have time. Over many years you have asked different pastors about the fate of gay people – theoretically of course. You have received several warnings about homosexual behavior. You believe being gay is a sin, and therefore you will be prevented from going to heaven in the afterlife—which is your central conflict. Without getting into the specifics of the Presbyterian religion, the important fact here is that the particular body of the church that you were raised in was conservative in its views on homosexuality. Therefore, the problem is how you reconcile who you are with what you were taught about being gay/finding salvation. Educational Background: You graduated from Oklahoma State University with a bachelor’s degree in Chemistry. You then attended medical school at USUHS and graduated near the top of your class in 2001. Military Background: You joined the Navy when you started medical school at the Uniformed Service University for the Health Sciences (USUHS-the only federally funded medical school in the country-you are commissioned upon entry.) If asked: “I decided to join the Navy because I wanted to see the world beyond Tulsa.” You were deployed to Tikrit, Iraq in 2008 and Helmand Province, Afghanistan in 2010, first as a Battalion Surgeon for 2nd Battalion, 7th Marine Regiment (referred to as 2/7 pronounced “two-seven”) then as Regimental Surgeon for 7th Regiment. Your position as 7th Regimental Surgeon was a nod to how well you performed running 2/7’s Battalion Aid Station (referred to as “BAS”). You deployed both times from Marine Corps Air Ground Combat Center (MCAGCC) Twentynine Palms, CA, your first duty station after graduating USUHS. You proceeded to residency after your second deployment. Note: Deploying with the Marines is commonly referred to as going “greenside” in the Navy. Remaining on ships/submarines etc. is “blueside” or “big Navy.” The chaplains may use these terms with this Service Member. While downrange (deployed overseas, usually in a war zone), you saw horrific wounds that service members suffered from gunshots, RPGs (rocket-propelled grenades), and IEDs (improvised explosive devises-these are commonly used as roadside bombs), However, you have a “naturally positive attitude” which you feel helped you to cope with this. You never talked to anyone in behavioral health about the things you saw/experienced. If asked: “I have very few nightmares about my experiences.” You are a Lieutenant Commander (O-4, an officer, often referred to as “Commander”) and the head of the Endocrinology/Diabetes Clinic at the Naval Medical Center Portsmouth (NMCP) located in Portsmouth, VA. You have been at your current posting for 6 years.
	Timeline of Events:
Timeline of Events (as relevant to predisposition to suicidal ideation):	Year/Month/Date     Event Lifelong struggle with identity. Two weeks ago-difficult date, since this happened you have been thinking about ending your life. Past week-you have been taking out your bottle of Valium and pouring yourself a glass of water.
Communication Preferences:	Before Suicidal Ideation – Verbal Communication Style : Articulate, confident, indicative of well-educated authoritative person. After Suicidal Ideation – Verbal Communication Style: Still articulate, but quitter than usual (Note: make sure you try to face the microphone so that you can be heard). A little less confident than usual. Before Suicidal Ideation – Non-Verbal, Physical Affect Preference : Professional, yet relaxed open posture. After Suicidal Ideation – Non-Verbal, Physical Affect Preference: Tense and closed off. (Note: since this is a formative exercise and there are only 2 SPs portraying Michela, take whatever tense, closed off posture feels authentic and natural to you.)
History of Present Mental Status:	Physical Symptom(s) : What is the symptom (e.g. Sometimes a physical symptom can manifest as part of a mental status issue/concern; If there is not a physical symptom present as part of this case authors can write “N/A”): Poor sleep, trouble getting to sleep. What is it like? (quality) bags under eyes, exhausted How bad is it? (quantity/severity) “I’m only sleeping 3-4 hours/night.” Suicidal Ideation Symptom(s) : When asked if you have “considered suicide,” you reply: “ I’ve been thinking of actually hurting myself over this. I’m looking at the Valium pills from an old back injury (you hurt your back in an old move). Thinking about not waking up and just not dealing with this anymore. I’ve never wanted to hurt myself before, but I’m just so tired.” If asked when you started thinking about a plan: “I’ve been thinking about this every day this week. I’ve taken out that bottle and gotten a glass of water.” (You have not gone so far as to take any pills).
	If asked what you think the problem is, you reply: “I just can’t be gay.” When did it start? (see timeline on previous page for further details): “It’s been this way my whole life.” Does anything make it better or worse? “ When I work a lot, I can almost forget.” If asked about your mood, you describe it as (use quote): “Awful, I’m terrified.” If asked how you coped with challenges in the past (e.g. in medical school, you reply: “I like a challenge—it helps me keep my mind off other things.” (You have always been able to put things into perspective in the past.)
Mental Health Assessment Questions:	SIGECAPS If asked about changes in habits for the following topics: Sleep – 3–4 hours/night Interest – Don’t want to hang out with friends; or use social media, etc. Guilt – Yes!!! Energy – Lower than normal Concentration – Fine, actively throwing yourself into your work Appetite – Not eating as well as you normally do Psychomotor – (e.g. Have you been feeling like you’ve been moving really slowly or having racing thoughts?) – No, but you are replaying the date in your mind over and over again. Suicidal Ideation (see entirety of this case for details) – yes, thinking of taking Valium since the bad date
Learner goals:	Emotional Regulation
Family medical history:	Father: 75; alive and healthy Mother: 72 alive and healthy Siblings: N/A Grandparents (if relevant): N/A
Current medications:	N/A
Sexual History:	5 previous partners (all women) – never had an STI
Lifestyle Risk Factors:	Drugs: No Tobacco: No Alcohol: One glass of wine/night (recently, sometimes two) CAGE questions address alcohol use, your responses include: Cutting back on alcohol, (Do you feel you should cut down?): No Annoyed, (Do you get annoyed when others ask about your drinking habits?): No Guilty, (Do you feel guilty when you drink?): No Eye Opener, (Do you need a drink in the morning?): No
Health maintenance practices:	Diet: Very healthy Exercise: Very active; 5 times/week at gym – treadmill and weight regimen. If asked: “I work out—it’s my drug.” Personal Safety (i.e. gun in the home): No

Rating Categories: Simulated Service Members assess learner skill(s) in Emotional Regulation:

Please use the following as a guide when making your ratings of the encounters at the Simulation Center. Please feel free to use any integer ranging from 0 to 6.

• 0 Made no attempt to meet objective -

  • □ Objective not addressed at all in the encounter

• 2 Made little attempt to meet objective -

  • □ Evidence that the learner did not understand the objective

  • □ Evidence that the learner did not personalize the content

  • □ Evidence that the learner did not address questions and/or concerns

  • □ Evidence that the learner did not show flexibility and persistence in the face of setbacks

  • □ Limited execution

• 4 Made a moderate attempt to meet objective -

  • □ Evidence that the learner understood the objective

  • □ Evidence that the learner personalized the content

  • □ Evidence that the learner did address questions and/or concerns

  • □ Evidence that the learner showed flexibility and persistence in the face of set-backs

  • □ Moderate execution

• 6 Skillfully met all aspects of objective -

  • □ Evidence that the learner mastered the objective

  • □ Evidence that the learner masterfully personalized the content

  • □ Evidence that the learner masterfully addressed questions and/or concerns

  • □ Evidence that the learner masterfully showed flexibility and persistence in the face of setbacks

  • □ Comprehensive execution

Module 4: Regulating Emotions to Control Suicidal Urges

• ____1. Explain the role of emotion dysregulation in elevating suicide risk.

• 0 Made no attempt to explain the role of emotion dysregulation in elevating suicide risk.

• 2 Made little attempt to explain the role of emotion dysregulation in elevating suicide risk.

• 4 Made a moderate attempt to explain the role of emotion dysregulation in elevating suicide risk.

• 6 Skillfully explained the role of emotion dysregulation in elevating suicide risk.

• ____2. Summarize adaptive and maladaptive functions of emotions.

• 0 Made no attempt to summarize adaptive and maladaptive functions of emotions.

• 2 Made little attempt to summarize adaptive and maladaptive functions of emotions.

• 4 Made a moderate attempt to summarize adaptive and maladaptive functions of emotions.

• 6 Skillfully summarized adaptive and maladaptive functions of emotions.

• ____3. Discuss the connections among thoughts, emotions, bodily sensations, and behaviors.

• 0 Made no attempt to discuss the connections among thoughts, emotions, bodily sensations, and behaviors.

• 2 Made little attempt to discuss the connections among thoughts, emotions, bodily sensations, and behaviors.

• 4 Made a moderate attempt to discuss the connections among thoughts, emotions, bodily sensations, and behaviors.

• 6 Skillfully discussed the connections among thoughts, emotions, bodily sensations, and behaviors.

• ____4. Assist in the identification of emotions (expansion of emotional vocabulary) and rating of their intensity on a continuum.

• 0 Made no attempt to assist in identification of emotions and rating of their intensity on a continuum.

• 2 Made little attempt to assist in identification of emotions and rating of their intensity on a continuum.

• 4 Made a moderate attempt to assist in the identification of emotions and rating of their intensity on a continuum.

• 6 Skillfully assisted in the identification of emotions and rating of their intensity on a continuum.

• ____5. Introduce at least two strategies for emotion regulation to prevent future suicidal crises.

• 0 Made no attempt to introduce any strategies for emotion regulation to prevent future suicidal crises.

• 2 Made little attempt to introduce at least one strategy for emotion regulation to prevent future suicidal crises.

• 4 Made a moderate attempt to introduce at least two strategies for emotion regulation to prevent future suicidal crises.

• 6 Skillfully introduced two or more strategies for emotion regulation to prevent future suicidal crises.