Teacher and actor perceptions of a recent journey involving clinical simulation

How to cite this article: Aleluia I, Carneiro AC, Fagundes M, Sestelo M, Brasil R, Soares T. Teacher and actor perceptions of a recent journey involving clinical simulation. Inter J Health Educ. 2021;5(1):xx-xx. http:// dx.doi.org/10.17267/2594-7907ijhe.v5i1.2871 Submitted 04/16/2020, Accepted 12/07/2020, Published 04/28/2021 Inter. J. Health Educ., Salvador, 2021 October;5(1):xx-xx http://dx.doi.org/10.17267/2594-7907ijhe.v5i1.2871 | ISSN: 2594-7907 Teacher and actor perceptions of a recent journey involving clinical simulation


Introduction
Medical education has experienced a series of changes, additions, and new perspectives referring to the teaching process. Traditionally, medical education is based on individual knowledge, attitudes centered around teaching, readings of scientific evidence, and practicing procedures on real patients. The fragmentation of knowledge into specialties and medical learning based on passive techniques, for example, theoretical lessons and written tests, demonstrably reduces knowledge retention and practical application. 1 Realistic simulation (RS) is one element in a new teaching method that involves technical skills and crisis management, leadership, teamwork, and clinical reasoning in critical situations or ones that may damage a real patient. The term "simulation" is currently used to describe several teaching methods for health professionals, leading to confusion about applying distinct strategies. 1 Terminology for specific technical skills or part-task trainers, the use of standardized patients, virtual reality, and highfidelity simulation are thrown together. However, they all encompass several areas in medical studies, such as cardiology emergencies, trauma, pediatrics, gynecology and obstetrics, intensive care, anaesthesiology, attitudinal skills for the doctorpatient relationship, and others.
In 1999, the Institute of Medicine's (IOM) report, To err is human 2 , revealed alarming data about patient safety, demonstrating that approximately 98,000 patients died annually in the United States due to errors during hospitalization. The report contained recommendations about training programs for interdisciplinary teams, incorporating "simulation" as a training method. It reinforced the importance of innovation and investment in training methodologies focused on learning and the practical application of learning acquired by health professionals. [2][3][4] Other strategies exist, such as the utilization of low and medium fidelity simulation mannequins, specific computer programs, and virtual games, which enable the simulation of a specific situation. Choice of strategy should be linked to the learning goal, prior participant learning, costs, and adequate teacher training. Simulation in medical education is already an established method, which expands possibilities for discussion and learning, with longer-term knowledge retention rates, and is more pleasant and pleasurable than traditional teaching. 1,5,6 The basic idea behind RS is to promote the integration of theoretical knowledge, technical and attitudinal skills, encouraging students to coordinate their skills simultaneously, thus facilitating the transfer of what is learned to solving new problems. 1,7 Skills in communication, leadership, decision-making, teamwork and skills for doctor or health professionalpatient, inter-professional and interdisciplinary relationships appear to be the greatest benefits for the training of future health professionals. 1,8 Most simulation studies aim to train specific technical or behavioral skills for residents or graduate professionals, hindering the methodology's full incorporation into the curriculum. 1 However, the use of RS, especially in graduate courses and particularly in Brazil, is relatively new. Its utilization has multiplied with the adoption of new technologies.
The simulation was not applied systematically in our institution. In the first semester of 2018, there was an opportunity to employ it more widely; this was related to strengthening skills-based teaching (teamwork, interpersonal communication, decision making, capacity to reflect about the practice) and to external challenges to get an adequate place in the practice fields in the health system, in a reduced offer to undergraduates' students. A pilot project was initially created to assess its acceptance and educational impact on both students and teachers.
Having this objective in mind, we began to identify when to include simulation in the curriculum and which teachers had the profile and availability to work with this model. We set up the Centre for Medical Simulation, responsible for planning the simulation project: scenarios, objectives, materials, and space. We invited 04 teachers from the fifth semester's Medical Semiology I module, interested in working with simulation techniques and the available workload. The journey began -a unique opportunity for teacher development, fully identified with the course and teacher needs. The collective construction method occurred naturally, transforming the group into a small practice community, where knowledge was shared and discussed, and reflections regarding practice were built. 9 During this journey, the community grew, with the inclusion of teachers from other courses (nursing and psychology) and the Griô theatre group, a theater research and practice group, from Salvador, and its mission is to take the theater to different spaces. That enabled an exchange of experiences and different viewpoints, analyzing the various angles of the creation process and allowing the group to develop its own identity. The group was composed of participants from diverse knowledge and experience areas, bringing respect and affection, all associated with academic educational rigor and in the interests of cooperation.

Methodology
The pilot project began in the second semester of 2018, and we initiated our meetings in June 2018.
We had eleven meetings, two and a half hours long, based on 'coffee and conversation.' We defined: 1. The themes to be addressed in the simulations: dementia, approach to cough, thoracic pain, and communicating bad news; 2. Teacher working hours: workload expansion required for course coordination; 3. Identifying teacher needs teacher development, mediated by the Institutional Programme for Faculty Development of our school(called Programa Institucional de Desenvolvimento Docente: PROIDD) with 30 hours duration; 4. The actors to perform the simulated patients: discussed with the theatre group according to the scenario's patient profile; 5. Educational goals for each case: the most important learning and reflection goal for the simulations; 6. The application format for each scenario: duration of scenario, discussion, geographic location, the weekly interval between scenarios; 7. Assessment: teacher field diaries and meetings between each simulation to assess and adjust as required. The pilot project began in September 2018 with excitement and anxiety regarding the first steps of a journey for both teachers and students… and the actors.
This investigation discusses the experiences of four teachers from the Clinical Skills discipline and two female actors at our Medical School (Escola Bahiana de Medicina e Saúde Pública). It aims to analyze reports of experiences from the first scenario using a realistic simulation, evaluate the project, and register the simulations' preparation process; we wondered to document their perceptions in this first moment of the experience. Participants were given the name of a flower to preserve their identity.
Data collection was based on each participant's narrative, constructed according to their memory of the experience in the second semester of 2018.
Since we are dealing with qualitative methodology, the teaching report narrates experiences recognized as significant for the subject and discusses them in a contextualized manner combined with information from the literature.
Inspired by Costa's experience with cartography, the work does not focus on a description of facts but instead discusses their degree of importance, not based on the perspective of social importance, but on what emerges from the body of the researcher, from the body they create from the things they encounter, feel and experience 10 . From this perspective, the work consists of a set of knowledge presented from the researcher's viewpoint, who, instead of describing truths, describes the journey so that new progress may occur, emphasizing the process of historical production.

Results
Analytically, theoretically, and methodologically, the report narrates the experiences of the four medicine/semiology teachers and the two female actors. Undertaking realistic simulation scenarios was an innovative and challenging experience for each one of them.
The first scenario involved an older woman with dementia, accompanied by her daughter, who wanted guidance and referral to support her mother. The students (117 divided into groups of 20 students throughout the week) were surprised but entered into the simulation, allowing the teachers to witness the final result of so many meetings, discussions, and uncertainties, while the actors enthusiastically entered into this process.
As limitations of this work, we can highlight that we show only the first scenario because the teachers' field journal was in this single moment.

Discussion
We know that simulation uses emotions to encourage learning. Witnessing this happening, being said, felt, and permitted, is exciting for the teacher. To create emotional baggage, to access memories that are useful for the health professional, to stimulate reflection in practice, to enable knowledge and perception of the feelings aroused during the meeting is fundamental for the training of a future health professional or doctor. We see this with the simulation -for both students and teachers, it is a process that goes beyond technique.
The analysis applied focuses on teacher and actor perceptions during the first simulation scenario, referring to care for a patient with dementia.
When we analyzed this first event, we perceived that we had attained our proposed objective. However, we also noted that the result went far beyond what had been determined: we were working with the subtle material we are all made of. We touched memories and stirred emotions. These feelings, thoughts, and reflections were treated with the same depth as the technical goals, demonstrating the balance required when caring for people.
The first teacher, whom we will call Begonia, described her experience thus: "I was responsible for running the first class.
The classroom contained everything we had planned; the students were separated from the simulation environment by the glass and the speakers for the microphones used by the actors and the volunteer student in the simulation.
I explained to the students that this activity was new to this subject that the faculty had contracted actors, and they applauded; they were enthused. One of them needed to be the "doctor" to simulate a scene of outpatient care (…) The actors had already received their directions in a prior "briefing," I guided the student, provided some questionnaires, and asked her to do what she thought was most relevant for the patient's situation.
During the scene, the student applied the Mini-Mental State Examination with no difficulties, concluded her suspected diagnosis, and recommended a consultation with a specialist.
We discussed feelings and conduct in the debriefing.
We first talked about the volunteer student's emotions and those of the other students, the distress surrounding a doctor when dealing with an uncooperative patient, one who presents difficulties in or is incapable of responding to simple questions (…). The actors praised how the volunteer student responded to them and talked about how they felt and how they were happy to perform in this kind of activity, which was also new to them.
(…) My feeling was one of accomplishment, given the organization of the project and pure emotion in seeing the students' receptivity and pleasure in this new activity. I see it as providing an opportunity to work in various situations that may significantly support the students' growth." These words lead us to an initial technique necessary for developing simulation, one which immediately moves to work with emotion, with the possibility of constructing attitudinal skills in a new way. That is in keeping with the literature 5 , both in its approach to attitudes and the importance of the debriefing as a moment for reflection and learning. 11 The second teacher, whom we will call Rose, describes her experience thus: "Initially, I presented the activity to the students, informing them of its objective. There would be no Semiology grade assessments for this activity (…) The student was attentive and followed the right procedure for receiving a patient in a medical consultation, the story was extracted properly and, out of the forms that were on the table, the student chose to apply the Mini-Mental State Examination (…). Everyone agreed that this was a very common real-life situation and cited the various feelings they experienced: "To be in the patient's shoes," "Humanity in treatment," "Feeling insecure when applying the test," "Attention and sensitivity," "Sadness on noting that this person used to be a different person," "Concern about transmitting the seriousness of the situation to the carer," "Concern about caring for the carer." We see the possibility of dealing with common reallife themes in ways that go beyond technique. These words elucidate the sensitive dimension of the simulation. That is in line with Mitre 8 , who addresses the importance of active teaching methodologies for learning which surpasses cognition and accesses creativity, affectivity, and autonomy.
The third teacher, whom we will call Daisy, described her experience thus: The fourth teacher, whom we will call Jasmin, describes her experience thus: "At the beginning of the activity, I explained to the students that we were working with a simulated scenario with two female actors. At that point, one of them needed to be the "doctor" to attend to a family whose mother had memory impairment. (…) They should feel safe and secure in that environment since it was essential to keep confidential information. I went on to say: "We expect strong emotions, and it is not ethical to comment on what takes place during a consultation or an experience." "Exercise ethics and care for the other." Do you accept the challenge? Of course, they were afraid. It was something new; they didn't know what it would be like… some had heard that it was something cool… but it took time for them to take action until one of them came forward. In Thursday's group, it was Flor, and in Friday's, it was Linda.
(…) I understand the scenario to be something greater than the scene created by the group of teachers (…). This scenario, in particular, refers to my memories of my mother and her dementia. My feeling was pure emotion, and seeing the scene as it developed, taking on flesh and becoming a reality with great actors, and seeing the care the students took in receiving them, trying to reassure them, working with empathy. The emotion of seeing them discussing their feelings, with shining eyes, their lived and genuine emotion, citing personal stories about their grandparents, how they would like someone to care for them… the affection and pain and at the same time feeling that they were safe to expose their ideas and feelings. (…) I cried many times … and I wasn't ashamed to tell the students that this was my story and how much emotion it awoke in me, since, in the end, we are all human and need to get in touch with our emotions to be able to deal with them in general and in our professional life. This last passage demonstrates the potential human encounter in training future professionals.
It makes it clear that the simulation opens up another perspective for teaching, which incorporates both technique and sensitivity, stimulating reflection about oneself and the other. What is described in all these speeches is the implicit potential of simulations to provide a secure environment for training future health professionals. 5,14 Below are the words of the female actors, whom we will call Camellia (daughter) and Angelica (mother): Camellia and Angelica raise the importance and difficulty of incorporating art and sensitivity into medicine. At the same time, however, they are explicit about the dialogue between technique and feeling, experience and reality in the construction of learning. 15 The simulation allows us to analyze the two sides of the situation (professional and patient), in their back and forth, in the ability to change places and experience each person's difficulties. That is a new possibility for training future professionals: they may observe themselves, may be observed, and discuss new pathways. There are no barriers or fixed images. The movement is real within the simulation, and the actors' view is fundamental. The actors enable this observation, this exchange with the student, with the teacher, since they represent the patient, they create the possibility of real-life within the theory, they arouse feelings and reflections and provide their perceptions of the consultation. They experience the character and enable the student to create their own character, with everything that this creation represents in the established doctor-patient relationship.
The teachers wrote up their perceptions and reflections about the process provided a new consciousness about practice. It enabled shifts and freedom in narrating the experience, in what was observed, and how this process impacted professional training: teacher and student. 16,17 Final considerations Positioning simulation within the Medical Semiology teaching process led to a number of gains and reflections. In the first place, it helped to strengthen the attitudinal skills (empathy, ethic, sensitive listening, communication) addressed in the curricular component. Within this, it strengthened teacher development in the group, encouraging new skills for the teachers.
Inter-professional education was seen in establishing relationships with other courses at the institution, expanding discussions and work between teachers and students, and including actors in the process. The movement between art and academic technique took place over a space that had been jointly created and with bilateral gains.
The importance of including simulation in health teaching was evident from the words of both the teachers and the actors as a factor capable of providing the changes and reflections required when training health professionals.
The simulation continues in the clinical skills, with more scenarios. Other studies should happen better to analyze the teaching learning process in this model.

Author contributions
Aleluia IMB participated in the project design, data collection, analysis, writing, and final review. Sestelo M and Brasil R participated in the project design, analysis, writing, and final review. Carneiro AC, Fagundes M, and Soares T participated in the project design, writing, and final review.

Competing interests
No financial, legal, or political competing interests with third parties (government, commercial, private foundation, etc.) were disclosed for any aspect of the submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation, statistical analysis, etc.).