Exploring engagement and emotional response to realism during simulation-based education: a mixed methods observational cohort study

Greene, Leah (2024) Exploring engagement and emotional response to realism during simulation-based education: a mixed methods observational cohort study. Doctoral thesis (PhD), Manchester Metropolitan University.

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Abstract

Introduction: simulation-based education has been used as an innovative technique for healthcare education for over a century. Tools and frameworks are available to guide the design of scenarios, however, techniques used are changing due to digital innovation. Supporting literature: there are misconceptions associated with simulation fidelity and realism and evidence to investigate the impact of differing variations of realism on learning, engagement, and performance. However, a gap in the literature was identified regarding the effect of varied levels of realism on learner’s knowledge, emotions, and behaviours. Methodology: Bandura’s Social Learning Theory was the theoretical framework that guided this research. A research question, study aim, and objectives were generated to explore different simulation-based education scenarios, to discover whether realism had an effect on the quality of the learning experience, leading to enhanced knowledge, and positive emotions and behaviours. Constructionism was the broad philosophical underpinning; symbolic interactionism the theoretical perspective, and a dramaturgical approach was taken to conduct this study. Methods: an observational cohort study using concurrent embedded design was conducted where the cohort were observed during three different scenarios (Manikin scenario, Human simulated patient scenario and a Paper-case). A feasibility study and pilot study were conducted, with the results used to inform and guide the main research study. Mixed methods were employed; quantitative data to explore the research question and qualitative observational data to provide context and background. Methods included pre- and post-measurement of learner’s knowledge and emotions via self-reported questionnaires, baseline self-efficacy measurement, post-intervention realism assessment, plus observation of behaviours using both structured and unstructured participant observation. Findings: student learners (n=11) from a Pre-registration Masters in Physiotherapy programme participated in the study; n=9 (82%) were female, majority aged 21-30 years (n=7, 64%). There was a difference in realism between simulation modalities – the Human SP scenario was significantly more realistic than the other two modalities (p<0.001). Post-knowledge scores were significantly higher following the Human SP scenario (26/40) and Paper-case (29/40) (p=0.01). Knowledge scores decreased following the scenario with a Manikin (21/40-19/40); this difference was not significant (p=0.6). There was a statistically significant increase in pre/post knowledge following the scenario featuring a Human SP (p=0.01). There was no difference in self-efficacy between the different scenarios (p=0.42); all learners reported high self-efficacy. Interest was the strongest pre-scenario positive emotion; Fear was the strongest pre-scenario negative emotion. The Manikin scenario caused more negative emotional responses, and the Human Simulated Patient scenario produced more positive emotional responses. Overall, all negative emotions pre- and post-Paper-case were less intense than the other modalities. Six themes were generated from the unstructured observations related to learner’s behaviours during each of the three scenarios. Discussion: The Human SP scenario was perceived to be the most realistic modality; this realism enhanced the learner’s experience, producing a significant knowledge gain, positive emotional response, and positive behaviours. The Paper-case was perceived to be the least realistic; however, this did not inhibit the learning experience, as learners gained the highest post-knowledge scores following interaction with the Paper-case, which may be due to the lack of distraction, creating an optimum area for learning. The Manikin scenario was perceived to be not as realistic as the Human SP scenario; it produced negative emotional responses and more negative behaviours; however, manikin-based simulation is necessary in some instances for certain procedural simulation scenarios that may be harmful to a human simulated patient. Conclusion and recommendations: Considerations are needed when making decisions about the modality and level of realism of simulation-based education prior to the scenario design process. A conceptual framework outlining the interrelationships between systems and subsystems associated with simulation-based education is presented. An appreciation of learner’s response to realism should enhance the learning experience and ensure appropriate design and delivery of simulation.