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1 | Research question: Employ a scoping review to determine what is known about simulation-based learning methods of creating illness and care experiences for health professions and the impact on their empathic skills | * Ongoing trial | ||||||||||||||||||||||||
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3 | Article details | Nature of illness and care that was simulated | Impact of simulation on the healthcare professional (student) | |||||||||||||||||||||||
4 | No. | Paper | Study / article type | Year of publication | Location of study | Participants professional healthcare background | Aim of study (if applicable) | Number of particpants (if applicable) | Article / paper keywords | Condition / illness / care experience being simulated | How the illness experience was simulated | Duration of simulation | Length of follow-up (if applicable) | Outcomes (with effect sizes when available) | How was impact determined? (e.g. questioniare type, interview etc) | Impact on learner? (if yes - insert description) | Authors' conclusion (cited) | References | ||||||||
5 | 1 | (Addison & Morley, 2018) | Qualitative study | 2018 | USA | Hospice and paliative care staff | To increase empathy levels in hospice and palliative care staff within the agency. | 101 | Empathy, symptom, disease, simulation | Palliative care | Breathing exercise that mimics shortness of breath and air hunger by breathing through a cocktail straw for 1 minute, participants are assisted with donning equipment simulating cataracts (scratched googles), ascites (apron with weights), neuropathy (gloves), deafness and confusion (white noise headphones), shortness of breath (breathing only through a straw), and stroke (weights on one side of the body). Participants were led into a room to perform sorting clothing, counting change, setting a table, pouring water into cups, and reading and signing a consent form. During this time, the participant hears background noise and endures “staff” talking over and about them. | 5 min | Immediate & after 10-months | Common feelings of desperation, fear, anxiety, panick, and exhaustion. Getting in touch with one’s empathy translated to behavioral changes that participants planned on making (including appropriate empathic verbal responses to patients). Some exhibited strong emotional reactions and needed additional debriefing to process feelings. | Post-experience debriefing, empathy survey, discussion, and evaluation. | Increased perceived empathy for patients and families in hospice and palliative care. After 10-months - direct positive correlation between increasing empathy levels after participating in the symptom simulation class. | ,,In summary, the symptom simulation exercise proved to be a vital component of the onboarding process for health-care providers in multiple settings including empathy training. The manner in which empathy training is conducted is crucial to the learning experience and internalization of this highly needed skill. Not only did the participants enhance their sense of empathy, they noted a life-altering journey spurned by this experience through self-reflection, learning, and gratitude. This program at Transitions LifeCare has been the single most powerful experience for new employees during their onboarding period." | Addison P, Morley C. Empathy Training Through Symptom Burden Simulation. Am J Hosp Palliat Med 2019; 36: 169–171. | ||||||||
6 | 2 | (Gugliucci & Weiner, 2013) | Qualitative longitudinal study | 2013 | USA | Medical students | Higlight the Learning by Living Project conducted with medical students at two Jewish Home Lifecare facilities as a representative example of community-based experiential learning. | 3 | Experiental learning, Health Professions Education, nursing homes, qualitative research | Old age | Assumed a role of the nursing home resident released from hospital emergency room with complete diagnosis of dominant side weakness from a stroke and pneumonia secondary to aspiration requiring student to remain in a wheelchair for at least 5 days. Had 1-2 persons assisstance when transferring from the chair to bed/toilet, to be bathed, and to eat pured food and drink thickened liquids (24h-36h) before consuming a normal diet again. Full clinical assessment was performed by nurse. Contact with Dr. Gugliucci was kept assuming role of a daughter of an elder parent. Taking medication (M&Ms) and experience care procedures residents with similar procedures may get. | 2 weeks /24/7 | Immediate, daily for 17-20 days. | Simple everyday tasks (going to the bathroom, washing up in the morning, dressing/undressing, eating meals, and moving around in the environment) were monumental, timeconsuming and humbling tasks. Lost independence for the experience. Afraid to make too much work for the staff, did not want to keep asking for things, nor ring the assistantce bell. Importance of taking medication on time. | Daily journals | Excitement and anxiety while entering a nursing home, frustration with wheelchair on the first days, dependance on nurses. New found skills: a) importance of physical touch; b) enhancement of communication by being at eye level regerdless of wheter the person is in a bed, a wheelchair, or on a treatment table; c) communication with authenticity and sincerity that comes from being comfortable with oneself; and d) connection with awareness of the person rather than merely treating the disease or frailities. Realisation about importance of relationships, friendships and the role of family as informal caregivers. Realisation of inability to support dignity of older patients throughout bathroom procedure only after interacting with 25 year-old student. | "To date, all students have completed their extended stay successfully and stated that this experiential learning project provided life-altering medical education. Longitudinal data reveals that students' maintain patient-centered attitudes and skills such as the use of eye contact, touch, body position, and voice cadence with patients of all ages. Barriers to working with older adults are decreased; understanding is gained by "walking in an older person's shoes". Both Jewish Home campuses benefitted by contributing to the field of aging and providing staff with true and heartfelt sense of the life of a resident. "The fact that the studens were so into their roles enhanced staff sensitivity and compassion. this was real and provided a window pf opportunity to learn from inside out" (Administrator, Sarah Neuman Home)." | Gugliucci MR, Weiner A. Learning by Living: Life-Altering Medical Education Through Nursing Home-Based Experiential Learning. Gerontol Geriatr Educ 2013; 34: 60–77. | ||||||||
7 | 3 | (Blaszczyk et al., 2018) | Polypharmacy qualitative study | 2018 | USA | Third-year pharmacy students | Determine the effectiveness of the JPSE to inculcate student empathy for those managing multi-drug, multi-dose medication regimens. | 152 (146) | Polypharmacy, simulation, empathy | Medication | Picking up the prescriptions at an assigned location (i.e., “the pharmacy”) during “pharmacy hours,” (8-prescription regimen to be managed for a week). | 7 days | Immediate | Increase in empathy (open-ended responses refflected personal growth in many respondents). | Kiersma-Chen Empathy Scale + Likert-type scale; open-ended response was categorized as “empathy” or “no empathy” by each of the four authors. | Increase in empathy. | "Overall, the JPSE was a successful simulation exercise in increasing empathy in pharmacy school students, and the IPE implications of this exercise can be fodder for future research." | Blaszczyk AT, Mahan RJ, McCarrell J, et al. Using a polypharmacy simulation exercise to increase empathy in pharmacy students. Am J Pharm Educ 2018; 82: 259–266. | ||||||||
8 | 4 | (Brown, 2010) | Qualitative study | 2010 | USA | Introductory psychology course undergraduates | Examine the efficacy of a brief auditory simulation on mental illness stigma across two listening conditions. | 127 | Stigma, education, simulation, hallucinations | Auditory hallucinations | An audio segment to simulate the experience of auditory hallucinations was adopted from a standardized workshop, A Training and Simulated Experience of Hearing Voices that are Distressing. During these simulations, both non-voice (e.g., faint rhythmic sound) and voice (e.g., repeated phrases, whispering, laughing) sounds are presented. 16-min sub-sample (minutes 3:58–19:38) of the entire 42-min simulation was used. | 16 min | Immediate? | Decreased self-reported willingness to help or interact with individuals with a mental illness, did not appear to engender goodwill or a desire to have contact, but rather facilitated social distance—the preference for greater proximal distance and less interpersonal contact. Increase in attitudes regarding forced treatment for those individuals with mental illness was noted. | Attribution Questionnaire | Changes in mental illness stigma, as evidenced by changes on 2 of the 4 dimensions of attitudes towards individuals with mental illness. | "The results of this study suggest that brief simulations of auditory hallucinations may alter aspects of mental illness stigma - less willingness to help/interact and greater attitudes for forcing treatment. However, a firm recommendation for or against the use of brief simulations is tenuous at this time. The findings in this study should not be used to interpret the efficacy of the workshop, A Training and Simulated Experience of Hearing Voices that are Distressing. This study did not fully implement the 3h multi-component (e.g., lecture, full simulation, discussion group) workshop which also had additional goals beyond addressing mental illness stigma. It is unclear whether the intervention was generally ineffective or the necessary components of an educational intervention (e.g., sufficient duration, providing a personal context) were absent. Although these brief simulations have great potential for wide implementation as they are relatively easy to disseminate (via mail or internet), cost-effective, short duration (less than 20 min), and require little effort for the administrator and participant, an assessment of their efficacy (and further development) is tantamount prior to such implementation." | Brown SA. Implementing a brief hallucination simulation as a mental illness stigma reduction strategy. Community Ment Health J 2010; 46: 500–504. | ||||||||
9 | 5 | (Brown, 2008) | Systematic study | 2008 | USA | Introductory psychology course undergraduates | How simulations of auditory hallucinations impact a non-clinical negative affect and decrease positive affect from baseline. | 504 | Hallucination, simulations, reactions, schizophrenia | Auditory hallucinations | In each sample, 1-2 audio segments were played to simulate the experience of auditory hallucinations. The audio segments were adopted from a standardized workshop, Hearing Voices That Are Distressing. During these simulations, both voice (e.g., repeated phrases, whispering, laughing) and non-voice sounds (e.g., faint rhythmic sound) were presented. | 4/8/12 min | Immediate | Higher levels of negative affect and lower levels of positive affect during the simulation conditions. | The Positive and Negative Affect Schedule-Expanded Form (PANAS) (prior and post) | The simulations increased negative affect and decreased positive affect. However, simulations with derogatory content led to greater increased negative affect and decreased positive affect than simulations with benevolent/neutral content. | These results suggest that the content of simulations have a substantial effect, which is pertinent to administering simulations for training purposes and implementing psychosocial rehabilitation programs for those who hallucinate. In sum, the results in this study indicate that simulations of auditory hallucinations have a significant emotional impact, which appears to be fairly robust. This effect was present among both men and women and this remained across differing variations (duration, volume, context) of the simulation. The impact was greater when presented with derogatory content. These results are particularly compelling for a number of reasons. The systematic study of individuals’ reactions to simulations has not been previously conducted. Here, four distinct studies using a large number of participants were utilized in an effort to explore a number of variables. This design minimized concerns about fatigue or habituation to the simulations, and quantitative measurements of the emotional reactions were utilized. This is a vast improvement over the existing anecdotal reports used to support the efficacy of the simulation workshops. Given the novelty of this research, a wide array of questions remains unanswered. Although the findings here should be considered preliminary, a number of workshop recommendations (36 min duration, active engagement in real world setting) are suspect. The question remains whether there are specific tasks or settings that are essential in administering influential simulations. Also, what is the effective duration of the simulations needed to have an impact on individuals? This forces the question whether there is a therapeutic ‘dose’ in terms of minimal time needed and maximal time in which there is no appreciable effect. Future research that expands on the variables examined in this study (e.g., duration, volume, context) can address some of these questions. The results of this study can potentially inform psychosocial rehabilitation programs. Consistent with previous research, auditory hallucinations have a pernicious effect on both negative and positive emotions among most individuals. Providers of psychosocial rehabilitation programs should remain vigilant for individuals who begin to or are currently hallucinating, and staff should be aware of how this experience may influence them. Experienced providers, such as Turkington et al. (2006) noted, “Affective responses to hearing voices (usually anger and anxiety) are often linked to unhelpful behaviors that maintain and exacerbate the voices.” (p. 369). Based on the results of this study, there is strong support that the presence of derogatory content in an auditory hallucination significantly increases negative affect and decreases positive affect. On these occasions, psychosocial rehabilitation providers may want to develop accommodations (e.g., breaks, alternative activities, etc.) in consultation with the individual. The acknowledgement of emotional impact may be particularly important in regard to cognitive behavioral treatment and more specifically cognitive restructuring. Turkington et al. (2006) noted in their review of cognitive behavior therapy for schizophrenia patients, “The content of voices can be usefully debated; for instance, if the voices are making abusive statements, the accuracy of these statements can be debated,” (p. 368). A therapist’s awareness of the emotional impact of particular auditory hallucinations (perhaps in- formed by formal assessment) could assist in selecting which auditory hallucinations to address first (i.e., target selection) and monitoring treatment outcomes." | Brown SA. Emotional reactions to simulations of auditory hallucinations. J Psychopathol Behav Assess 2008; 30: 307–314. | ||||||||
10 | 6 | (Brown et al., 2010) | Mixed-methods study | 2010 | USA | Introductory psychology course undergraduates | Examine the impact of two brief interventions towards altering individuals’ attitudes toward those diagnosed with schizophrenia. | 143 | Stigma, education, contact, simulation | Auditory hallucinations | A 16-minute audio segment was played to simulate a credible experience of auditory hallucinations (educational intervention). | 16 min | Immediate and 1 week after | Increased levels of social distance and negative emotion immediately following the intervention were observed, which persisted (but decreased) 1 week later. Simulations were helpful in understanding mental illness and bolstering empathy. | Stigma measure, Symptom Checklist-90-revised, Quality of life inventroy, Social Distance Scale and Affect Scale (Prior and After) | The results from this study indicate that participants in the filmed contact and simulation intervention experienced changes in mental illness stigma (social distance and negative emotions) across time. The simulation led to increases in stigma. | "The efficacy of a hallucination simulations intervention remains dubious. The results of this study suggest that brief filmed contact decreases two aspects of mental illness stigma: social distance and negative emotions. Filmed contact interventions have great potential for wide implementation. A film such as, Living with Schizophrenia, is easy to disseminate (via mail or internet), requires little effort for the administrator and participant, is cost-effective, and requires less than 20 min. The implementation of a brief, effective intervention for decreasing mental illness stigma would be a formidable tool to address the real world consequences associated with stigma. A recommendation for or against the use of simulations is tenuous at this time. In contrast to anecdotal reports from workshops utilizing simulations, those in the simulation intervention in this and a previous study increased on mental illness stigma.1 It is unclear whether simulations are generally detrimental for stigma, or the necessary components for an effective educational intervention are missing and led to an unintended iatrogenic effect. To examine the full potential of simulations, they must be investigated in the context of other components." | Brown SA, Evans Y, Espenschade K, et al. An examination of two brief stigma reduction strategies: Filmed personal contact and hallucination simulations. Community Ment Health J 2010; 46: 494–499. | ||||||||
11 | 7 | (Bunn & Terpstra, 2009) | Qualitative study | 2009 | USA | Medical students | Assess third-year medical student empathy toward psychiatric pa- tients using the validated Jefferson Scale of Physician Empathy, Student Version (JSPE-S), before and after a simulated auditory hallucination experience. | 150 | - | Auditory hallucinations | Students listening to the auditory hallucinations presentation on individual headphones, underwent a psychiatric interview and simplified neurocognitive testing and were asked to socially interact in the community. They were asked to follow written directions to construct various geometric designs with wooden toothpicks and participate in a modified Mini-Mental State Examination, which assessed memory, concentration, fund of knowledge, and abstraction ability. Once the tasks were completed, the students were encouraged to walk around the medical center while listening to the simulated auditory hallucinations and (normally) interact with their peers. | 40min | Immediate | Increase in overall empathy score, easier to understand the behavior of patients with mental illness. | The Jefferson Scale of Physician Empathy, Student Version (Prior and Post) | Students’ empathy score increased, with an average difference of 2.65. | "These results suggest that empathy may increase when students are given a brief glimpse into the mind of a mentally ill patient by listening to simulated auditory hallucinations. Specific interventions to increase empathy for the mentally ill can lead to a better understanding of how empathy can improve patient care, enhance the doctor-patient relationship, and direct future educational strategies." | Bunn W, Terpstra J. Cultivating empathy for the mentally ill using simulated auditory hallucinations. Acad Psychiatry 2009; 33: 457–460. | ||||||||
12 | 8 | Chaffin & Adams, 2013) | Mixed-methods study | 2013 | USA | Senior baccalaureate nursing students | Teach psychiatric nursing students about the symptom of auditory hallucinations, or ‘‘hearing voices’’. | 67 | Auditory hallucinations, empathy, hearing voices simulation, psychiatric nursing students, education, schizophrenia | Auditory hallucinations | Each student listened to the CD of recorded voices while doing simple tasks. | 13-15 min + 5min | Immediate and after 4 weeks | Significant differences in students’ empathy. Students acknowledged more understanding of psychiatric patients and more empathy for the challenges patients faced. They wanted to show more patience during interactions. Change occurred in students’ ability to feel empathetic toward psychiatric patients and extend understanding to them. | 5-point Likert-type scale, open-ended questions | Speaking with deep emotion about the sadness for patients who could not turn off the voices. Students were more focused, showed extreme kindness and patience when interacting with the psychiatric patients, were more relaxed, had better use of verbal and nonverbal therapeutic communication skills, were motivated by the developed empathy, no longer judged patients and transcended their fears gaining understanding. | "Results supported an increase in students’ empathy after the simulation, and reflective statements showed they were changed by the experience. As a result of the Hearing Voices simulation, students intended to demonstrate more understanding, patience, and kindness toward patients in general. Qualitative results indicated students’ future practice will forever be influenced by the Hearing Voices simulation experience. It will motivate them to accept the patient, believe what the patient says, and respond appropriately when the patient describes voices that say to do harm." | Chaffin AJ, Adams C. Creating Empathy Through Use of a Hearing Voices Simulation. Clin Simul Nurs 2013; 9: e293–e304. | ||||||||
13 | 9 | (Chen et al., 2015a) | Quasi-experimental pretest-posttest design study | 2015 | USA | Sophomore-level baccalaureate nursing students | Examine the impact of participation in an aging simulation game on nursing students' empathy and attitudes toward older adults as well as their understanding of patients' experiences in the healthcare system. | 58 | Nursing student, empathy, geriatrics, attitude | Old age | In the Geriatric Medication Game, students “role-play” an older adult with assigned physical, financial, or psychological issues, navigate the health care system, and execute different tasks (eg, reciting their medication list, accurately filling a weekly pill box). Students must pay (using “health credits”) for health services based on their financial status. The simulated experience includes 6 stations: physician’s office, nurse practitioner visit, pharmacy, tests and benefits, “home,” and activities. Cards drawn at a station send students to another station, ask them to perform an activity, or add a new condition or medication. Station facilitators mimic real health care providers and exhibit different amounts of empathy or caring. | 3h | Immediate | Significant improvement in student empathy toward older adults and greater understanding of the healthcare system and older adult experiences. Demonstrated improvement in empathy after completing the GMG. | Kiersma–Chen Empathy Scale, Jefferson Scale of Empathy—Health Professions Students, and Aging Simulation Experience Survey, reflective discussion | Empathy (N = 58) toward older adults significantly improved overall (KCES p = 0.015, JSE- HPS p b 0.001). Improvements also were seen on seven out of 13 questions related to attitudes and healthcare understanding (p < 0.05). In the post-test, students agreed that they experienced frustration and impatience during the GMG. | "Development of curricular strategies, such as incorporation of the Geriatric Medication Game®, can emphasize the importance of empathy and caring to students. Students may not be aware of older adults' feelings and experiences prior to experiencing aging-related changes themselves, and simulation activities can be a useful mechanism to allow students to “walk in the shoes” of an older patient. Instruments such as the JSE-HPS, the KCES, and the ASES are tools that can be utilized to inform and guide faculty regarding whether a simulation ac- tivity or other educational activities result in improved student empathy and perceptions of older adults. These curricular strategies can assist future generations of nurses in improving attitudes and empathy toward older adults, resulting in improvements in the quality of care provided." | Chen AMH, Kiersma ME, Yehle KS, et al. Impact of the Geriatric Medication Game® on nursing students’ empathy and attitudes toward older adults. Nurse Educ Today 2015; 35: 38–43. | ||||||||
14 | 10 | (Chen et al., 2015b) | Quasi-experimental pretest-posttest design study | 2015 | USA | First-year pharmacy students | Evaluate changes in empathy and perceptions as well as game experiences among student pharmacists participating in an aging simulation game. | 156 | Empathy, attitudes, pharmacy students, geriatrics, game | Old age | In the Geriatric Medication Game, students “role-play” an older adult with assigned physical, financial, or psychological issues, navigate the health care system, and execute different tasks (eg, reciting their medication list, accurately filling a weekly pill box). Students must pay (using “health credits”) for health services based on their financial status. The simulated experience includes 6 stations: physician’s office, nurse practitioner visit, pharmacy, tests and benefits, “home,” and activities. Cards drawn at a station send students to another station, ask them to perform an activity, or add a new condition or medication. Station facilitators mimic real health care providers and exhibit different amounts of empathy or caring. An additional facilitator, acting as “fate,” visits students while they wait in line for a station and makes positive or negative changes in their health and well-being (eg, add a new medication, remove a disability). | 3h | Immediate | Students became more cognizant of older adults’ feelings and of the different treatment patients can receive based on their type of health insurance. Students experienced frustration when they were unable to complete a task easily. They reported significant improvement in their empathy and attitude toward older adults and perceptions of older adults’ experiences in the health care system. Students planned to provide assistance to older adults in their future practice, and try to be patient with older adults in the workplace. Students agreed that their attitudes toward older adults changed as a result of the game experience. | Kiersma–Chen Empathy Scale, Jefferson Scale of Empathy—Health Professions Students, and Aging Simulation Experience Survey, reflective discussion | Empathy using the KCES and JSE-HPS improved significantly. Of the 13 items in the ASES, 9 significantly improved. There were significant increases on 7 of the 20 items on the JSE-HPS. For the KCES, 14 of the 15 items had significant increases from preintervention to postintervention (p<0.05). Agreement significantly increased that it is necessary for a health care practitioner to be able to comprehend someone else’s experiences and to express an understanding of someone’s feelings. Students also responded with higher agreement postintervention that they were capable of seeing the world from another person’s perspective and valued someone else’s point of view. Student perceptions of older adults’ experiences in the health care system and of the health care system itself significantly improved for 9 of the 13 items on the ASES. | "Students who may not have spent time as a patient in the health care system may not understand the experiences of older adults. Incorporating aging simulation activities, such as the GMG, into the curriculum to address student empathy, attitudes, and perceptions may help students better understand the patient experience. Utilizing assessment instruments, such as the KCES and ASES, can help faculty members decide whether educational activities actually meet student outcomes and inform curricular design. Since empathy and attitude impact patient care, these curricular interventions may lead to improved care quality for older adults." | Chen AMH, Kiersma ME, Yehle KS, et al. Impact of an aging simulation game on pharmacy students’ empathy for older adults. Am J Pharm Educ; 79. Epub ahead of print 2015. DOI: 10.5688/ajpe79565. | ||||||||
15 | 11 | (Chen et al., 2011) | Quasi-experimental pretest-posttest design study | 2011 | USA | First-year pharmacy students | Examine the impact of participation in the Geriatric Medication Game on pharmacy students’ perceptions of and attitudes toward older adults and familiarity with common disabilities that affect them and the process of seeking health care. | 625 | Attitudes, pharmacy education, geriatrics, assessment | Old age | In the Geriatric Medication Game, students “role-play” an older adult with assigned physical, financial, or psychological issues, navigate the health care system, and execute different tasks (eg, reciting their medication list, accurately filling a weekly pill box). Students must pay (using “health credits”) for health services based on their financial status. The simulated experience includes 6 stations: physician’s office, nurse practitioner visit, pharmacy, tests and benefits, “home,” and activities. Cards drawn at a station send students to another station, ask them to perform an activity, or add a new condition or medication. Station facilitators mimic real health care providers and exhibit different amounts of empathy or caring. | 3h | Immediate | Improved attitudes toward older adults, greater knowledge and understanding of patient experiences, increased willingness to provide assistance. Experienced personal frustration navigating the healthcare system, dealing with disabilities and facing difficulties completing tasks. | 5-question reflection about the experience and attitudes toward olderadults, reflective discussion | >75% of students indicated they experienced frustration because many were given disabilities, such as vision or dexterity loss. 50% of students learned that disabilities make it challenging to complete the tasks required to navigate both the healthcare system and daily life. being more aware of older adults’ feelings, better understanding their experiences in the healthcare system, and realizing that older adults often face stereotypes or prejudice because of their age or disabilities. Nearly 88% of students agreed that their attitude had improved. Improved patience, willingness to provide more assistance, greater respect, and greater empathy for older adults. Nearly 40% of students learned that they often had to visit multiple healthcare providers, such as a physician, laboratory technician, and pharmacist, to resolve their health issues. A quarter of the students also learned that the US healthcare system can be costly, with copayments for office visits, laboratory tests, and prescription medications. 19% of students felt there was a lack of care coordination among healthcare professionals, which contributed to longer wait times, unnecessary trips to a healthcare provider, and potential errors. | "Incorporating the Geriatric Medication Game into the pharmacy curriculum may facilitate students’ understanding of the challenges that older adults face and improve future interactions. The Geriatric Medication Game was incorporated into the PharmD curriculum to address the ACPE standards and AACP outcomes regarding the display of professional attitudes toward and knowledge of patient populations. After participation in the game, written student reflections demonstrated that students met the learning outcomes for the activity. Students gained an understanding of feelings and emotions older adults may experience, improvement in their attitudes toward older adults, and knowledge regarding the US healthcare system. Furthermore, students indicated that they planned to make positive changes in their future practice based on this experience." | Chen AMH, Plake KS, Yehle KS, et al. Impact of the geriatric medication game on pharmacy students’ attitudes toward older adults. Am J Pharm Educ 2011; 75: 23–25. | ||||||||
16 | 12 | (Corr et al., 2017) | Qualitative interpretative phenomenological study | 2017 | UK (NI) | Fourth-year medical students | To explore the impact of wearing a melanoma tattoo on medical students’ understanding of patienthood and attitudes towards patients with melanoma. | 10 | - | Melanoma | The melanoma tattoo was applied to participants’ forearms, the recorded narrative was played, and instructed them to go about their normal lives for the next 24h. Participants were asked to reflect critically on the experience of receiving a diagnosis of malignant melanoma. After 24h participants were asked to remove the temporary tattoo using soapy water. | 24h | 4 times at regular intervals over 24h simulation, immediate interviews afterwards | Broadened and deepened perspectives and understanding, fostered patient-centred attitudes towards the experience of having this important form of cancer. Explored a less protected view of life and mortality. Reflected on what they took for granted in their own lives. Considered some of the ways to demonstrate compassion to patients. More often ‘the small things’ really counted. | Audio diaries, face-to-face interviews | Learned sociological and psychological perspectives on patienthood that went beyond the biomedical dimension of having a melanoma. Participants grounded these experiences by looking inwardly to themselves and what it might be like to have a melanoma diagnosis. They learned the meaning and emotional impact of illness on people’s lives, including how it constrains their actions. As with actual patients with cancer, a sense of loss, guilt and stigma were prominent experiences. | "By means of a novel simulation, medical students were introduced to lived experiences of having a melanoma. Such an inexpensive simulation can prompt students to reflect critically on the empathetic care of such patients in the future. The findings of this study indicate that by means of a novel simulation-based learning activity, it is possible to afford medical students a modest but potentially important introduction to some of the lived experiences of a patient who has a melanoma. Beyond the biological account from traditional teaching, the experience provides insights to patients’ life worlds. Overall, this simulation modality could complement traditional dermatology teaching methods, providing a greater appreciation of the patient, and their lifeworlds, behind the melanoma skin lesion." | Corr M, Roulston G, King N, et al. Living with ‘melanoma’ … for a day: a phenomenological analysis of medical students’ simulated experiences. Br J Dermatol 2017; 177: 771–778. | ||||||||
17 | 13 | (Darbishire et al., 2009) | Qualitative study | 2009 | USA | Second-year pharmacy students | To implement an active-learning methodology for teaching diabetes care to pharmacy students and evaluate its effectiveness. The purpose of this manuscript was to describe a unique instructional approach based on active-learning methodology when teaching diabetes care to pharmacy students. | 157 | Diabetes, active-learning techniques, practice laboratory | Diabetes | Students calculated carbohydrate servings needed to maintain individual body weights, formulated a carbohydrate distribution plan, used food replicas to build meals and make adjustments in daily carbohydrate allotments and role played pharmacist/patient interactions regarding nonprescription products and their nutritional characteristics. In the Medication Station they counseled a fellow student on the activity, preparation, administration, mixing and storage of insulin, performed an insulin (saline) self injection, examined a variety of insulin pumps, pens and supplies. In the Monitoring Station participants performed an individual blood glucose check and role played pharmacist/patient issues relating to monitor malfunction and misuse. In the Motion Station pre and post exercise blood glucose checks were performed, they reviewed the Standards of Care, performed a comprehensive foot exam on a fellow student and viewed replicas of diabetic feet with abnormalities (e.g., ulcers, blisters, infections). | 3h | Immediate | Improved confidence in providing care to diabetes patients, empathy for patients with diabetes, gaining a better understanding of what a patient with diabetes faces. Realized that more learning and practice was needed before becoming totally confident in providing diabetes management services. | Knowledge of diabetes evaluation, confidence in providing diabetes care evaluation, a laboratory evaluation. | Significant declines in confidence also were not seen: (1) I am a competent diabetes educator, (2) I can adjust carbohydrate servings to achieve blood glucose control, (3) I can list the American Diabetes Association’s recommendations for patients with diabetes, (4) I can perform a diabetes foot check, (5) I can describe the advantages and disadvantages between differing blood glucose meters, and (6) I can instruct a patient on how to prepare the hand for blood glucose testing. | "An active-learning approach to teaching diabetes care allowed students to experience aspects of the disease from the patient’s perspective. This approach will be incorporated in other content areas. Overall, students were positive in their evaluations of instructional content and methods. Over 90% of the stu- dents strongly agreed that the laboratory was interesting, helped them learn key concepts presented in lectures, and would help them apply skills in the ‘‘real’’ world. Students improved in their confidence and knowledge of diabetes care. Aspects of this teaching method will be incorporated into other content areas." | Darbishire PL, Plake KS, Nash CL, et al. Active-learning laboratory session to teach the four M’s of diabetes care. Am J Pharm Educ 2009; 73: 1–9. | ||||||||
18 | 14 | (de Abreu et al., 2017) | Qualitative study | 2017 | USA | Medical students, physician assistant students, pharmacy interns, and psychiatry residents | Raise learners’ awareness of, and attentiveness to, physical and cognitive changes experienced by the aging population. | 49 (48 completed both pre-post questionnaires?) | Geriatrics, education, medical students, cognitive dysfunction | Old age | To mimic cognitive and sensory impairment the simulation used: goggles (reduced visual acuity), a thick pair of gloves (limited manual dexterity), headphones playing distracting audio (impaired hearing), and provision of complex, multistep directions (cognitive impairment). Once having been fitted with the equipment, they were sequentially instructed to, “Dry the cup, then fill it with water and take one red pill. Place all remaining pills in the pill box”; “Fold two towels, one pair of socks and one t-shirt, and place them inside the bag in the following order: first the shirt, then the towels, and then the pair of socks”; and “Read the receipt, and make a check for $25. Place the check in the envelope and mail it to the writen address". | 10min | Pre/post (assumed immediate?) | Significant increase in positive attitude towards changes in the aging population. | The Approaches to Dementia Questionnaire | Statistically significant improvement in the Approaches to Dementia Questionnaire scores among participants indicating an increase in positive attitudes. However, almost all participants (96%) did feel that this intervention would impact their practice behaviors, After the participants completed the day-to-day simulation exercises, the ADQ mean subscores for H and PC were 27.35(SD = 4.15) and 50.04 (SD = 3.22), respectively. The mean post TS for the 19 items was 77.40 (SD = 6.13). | "On the basis of these findings, the simulation exercise can be used for improving learners’ attitudes towards those with cognitive impairment. There is a great need for healthcare providers for older people. Improving attitudes about aging and cognitive impairment has the potential to improve the care that older adults receive and deserve. Our intervention provides a model for an interactive training that attempts to address the increasing need for the care of older adults. The exercise was incorporated into the geriatric psychiatry rotation curriculum for BCM learners." | De Abreu ID, Hinojosa-Lindsey M, Asghar-Ali AA. A Simulation Exercise to Raise Learners’ Awareness of the Physical and Cognitive Changes in Older Adults. Acad Psychiatry 2017; 41: 684–687. | ||||||||
19 | 15 | (Dearing & Steadman, 2009) | Qualitative interpretative phenomenological study | 2009 | USA | Senior year nursing students | Understand the lived experience of voice simulation with the novice nurse as they enter the psychiatric/mental health clinical rotation and to describe the impact on the nurse's empathy and desire to develop a therapeutic relationship. | 28 | Intellectual empathy, novice nurse, therapeutic relationship, voice simulation | Auditory hallucinations | Audiotape presentation simulates a voice-hearing experience including whispers, noise, and intrusive words or messages. Each participant was given a tape player, the audiotape, and headphones. The participants were instructed on the use of the equipment and asked to place the volume of the recorder at a level that allowed them to hear the tape as well as the noise in the surrounding environment. As participants were listening to the tape, they were to participate in 4 activities, which included answering simple math problems, arranging toothpicks into specific shapes, interacting with a mental health professional during a minimental status evaluation, and answering written questions after reading a journal article. | 45 min | Immediate | Experienced heightened emotions in the category of intense feelings. As the simulation continued, feelings of anger, vulnerability, and fear became more overwhelming. The ability of the participants to maintain focus regarding cognitive processes began to deteriorate with the constant hearing of noise, whispers, and voices, which can be summarized as incoherent thinking. Experienced feelings of exhaustion and being physically drained. Participants felt depleted coping reserves. Described a sense of insight about what hearing voices must be like for people with mental health problems. Students felt they could empathize with this type of suffering. Anticipated being able to change their thinking and attitudes to truly focus on the development of therapeutic relationships. | Writing of a reflective account on items: First, “Describe how you were feeling during the voice simulation experience.” Second, “Describe the physical effects of the voice simulation.” Third, “Relate how the voice simulation experience will affect your nursing care with patients who experience auditory hallucinations.” | A sense of insight was developed, and participants felt they could empathize with this type of suffering. The ability to change attitudes to focus on the development of therapeutic relationships was enhanced. Voice simulation assists the novice nurse in developing intellectual empathy. Initially, the participants found the simulation experience stressful and had difficulty listening. After a short period of time, they described more intense feelings, moving to an increased feeling of vulnerability, fear, anger, and finally anguish. Increasing discomfort, anxiety, and, finally, exhaustion described a sense of insight about what hearing voices. Identified differences in their thinking and attitudes that would lead to a change in their demeanor and behavior. Others shared the changes in attitude and resulting enhancement of their role. Increased ability to establish a therapeutic relationship and advocate for coordination of care for this group of individuals. | "Through the lived experience of the VSE and participants’ descriptions of their feelings and thoughts, five major categories were identified. First, partici- pants experienced heightened emotions in the category of intense feelings. As the simulation continued, feelings of anger, vulnerability, and fear became more overwhelming. Second, the ability of the participants to maintain focus regarding cognitive processes began to deteriorate with the constant hearing of noise, whispers, and voices, which can be summarized as incoherent thinking. Hassled being, the third category, was described by the participants as experiencing feelings of exhaustion and being physically drained. Participants felt as though coping reserves had been depleted. Fourth, participants described a sense of insight about what hearing voices must be like for people with mental health problems. This category of intellectual knowing allowed the participants a glimpse into the life of a person who experiences auditory hallucinations, and they felt they could empathize with this type of suffering. The fifth category of Apt acting is important to the participants’ nursing practice because it illustrates that they could anticipate being able to change their thinking and attitudes to truly focus on the development of therapeutic relationships. Writings of the participants demonstrate that, for a few moments, they were able to step into the life of those who experience mental illness. As Heidegger (1962) relates, experiences can only be understood in the social context. In this exercise, nurses were able to understand the illness experience of hearing voices and experience firsthand how this would affect their lives. Developing a relationship with clients and entering their world require that the nurse empathize with them. Theory and speculation do not help the nurse develop empathy, and, often, nurses have difficulty with empathizing with experiences that seem totally foreign to their social world. The VSE provides a type of real-life understanding of hearing distressing voices, thus providing emotional intelligence." | Dearing KS, Steadman S. Enhancing Intellectual Empathy: The Lived Experience of Voice Simulation. Perspect Psychiatr Care 2009; 45: 173–182. | ||||||||
20 | 16 | (Dearing & Steadman, 2008) | Mixed-methods interpretative phenomenological study | 2008 | USA | Nursing students | Determine nursing students' perceptions and attitudes toward patients who experience auditory hallucinations and whether an orientation process that includes a VSE changes students' attitudes and increases their ability to interact with patients with auditory hallucinations. | 94 (52 - voice simulation; 42 - none) | - | Auditory hallucinations | Audiotape presentation simulates a voice-hearing experience including whispers, noise, and intrusive words or messages. Each participant was given a tape player, the audiotape, and headphones. The participants were instructed on the use of the equipment and asked to place the volume of the recorder at a level that allowed them to hear the tape as well as the noise in the surrounding environment. As participants were listening to the tape, they were to participate in 4 activities, which included answering simple math problems, arranging toothpicks into specific shapes, interacting with a mental health professional during a minimental status evaluation, and answering written questions after reading a journal article. | 45 min | Immediate | Expressed a desire to improve ability to interact with patients. The importance of good communication skills was paramount in caring for patients with auditory hallucinations. Participants would suspend judgment, try to be more understanding, and consider the patient's point of view. They described the necessity of excellent listening skills using respect, empathy, and patience; and of believing patients as they talked about the voices they hear, the need to be proactive with patients, need to research the illness, including the etiology, symptoms, and treatment. They also discussed the need for communication with the treatment team and referral to experts for consultation and assistance with complicated symptoms. Reduced stigmatizing perceptions, enhanced empathy and student insight, and to improved the development of the nurse-patient relationship. | Medical Condition Regard Scale (MCRS) and The 11-item demographic questionnaire, focus group | Nursing students demonstrated a change in attitude, believing they can develop a significant therapeutic relationship with those who experience auditory hallucinations (p = 0.000) and that treatment provided to patients is beneficial and cost effective (p = 0.05). The participants were able to explain new insights into the patients' world. They expressed becoming more empathetic. | "Role-play, standardized patient scenarios, drama, and theater have been used as modalities for student learning. Developing case studies, scenarios, or simulations to benefit student discussion and learning is necessary to help students to empathize and develop therapeutic relationships with their patients in mental health nursing. This is a challenge for students who have not been exposed to patients with auditory hallucinations. Voice simulation is one tool that can be used to reduce stigmatizing perceptions, to enhance empathy and student insight, and to improve the development of the nurse-patient relationship. As stated by one participant who experienced the VSE, "I now have a greater respect for people with mental health issues. certainly know if a patient comes in hearing voices, will believe him. Certainly it's not something he's making up. will listen more and listen to the experiences. have a greater respect for what [patients with mental illness] have to go through."" | Dearing KSK, Steadman S. Challenging stereotyping and bias: A voice simulation study. J Nurs Educ 2008; 47: 59–65. | ||||||||
21 | 17 | (Delea et al., 2010) | Qualitative study | 2010 | USA | Third-year pharmacy students | Determine the change in students’ attitudes about type 2 diabetes and impact on students’ confidence in diabetes self-management education skills by integrating the intervention of a Living With Diabetes Week simulation into the curriculum. | 187 (77) | Diabetes, attitude, assessment, simulation | Diabetes | Students were provided with a ‘‘diabetes diary’’ consisting of several logs to record when self-care tasks were performed. Participants performed diabetes medication administration (administration of ‘‘metformin’’ (hard candy) twice daily and ‘‘insulin’’ (normal saline) 1 to 4 times daily), self-monitoring blood glucose (use of glucometer to check blood glucose levels 3 times daily), diet (monitor and record all meals/snacks/drinks ingested: normal diet (reflect on current carbohydrate intake) and medcal nutrition therapy (carbohydrate counting), (monitor and record all exercise performed), foot examination (perform diabetes foot self-care), self-reflection (reflect on experience living as a patient with diabetes). | 1 week | Immediate | The understanding that diabetes has a psychosocial impact, patient autonomy is necessary, and the seriousness of the disease increased. Students’ confidence in their diabetes self-management education skills also increased. | 40-item anonymous survey | Increased confidence in diabetes self-management education skills because they had experience ‘‘living with the disease.’’ The majority of students’ comments involved a greater appreciation of how difficult and demanding it was to be a patient with diabetes. The greatest difference in confidence occurred regarding making recommendations to other health care providers about diabetes management, using a blood glucose diary to make recommendations for changes in diabetes medication management, and in the overall ability to provide appropriate education to patients with diabetes. | "The Living With Diabetes Week simulation changed pharmacy students’ attitudes toward patients with diabetes and increased confidence in diabetes education skills. This study involved including a week-long simulation of living the life of a patient with type 2 diabetes within a traditional diabetes curriculum with the goal of changing students’ attitudes toward diabetes and increasing confidence in diabetes self-management education. Pre-/postintervention, experimental, and control groups were used to assess students’ attitudes related to diabetes. Implementation of the Living With Diabetes Week simulation changed pharmacy students’ attitudes toward patients with diabetes. Specifically, it increased pharmacy students’ beliefs in the psychosocial impact of diabetes, and the belief that patients with diabetes should have autonomy regarding treatment of their disease state. Furthermore, implementation of the Living With Diabetes Week simulation increased pharmacy students’ confidence in diabetes self-management education skills." | Delea D, Shrader S, Phillips C. A week-long diabetes simulation for pharmacy students. Am J Pharm Educ 2010; 74: 130. | ||||||||
22 | 18 | (DelPrete et al., 2016) | Qualitative study | 2016 | USA | First-year medical students | Gauge the efficacy of educational patient-role scenarios on maintaining medical student empathy when compared with a curriculum without such activities. | 118 (86) | Empathy, medical student, jefferson scale of physician empathy | Diabetes mellitus | The activity included taking daily “medication" (2 pill bottles: one containing a four-day supply of M&Ms (twice a day) and one containing a four-day supply of Tic Tacs (once a day before breakfast), consistent with dosing instructions for metformin and glyburide, respectively. The pill bottles contained instructions for taking the “medications” as well as common side-effects.), participating in moderate exercise (20min 2-3 times over the course of the regimen), and maintaining a low carbohydrate diet (less than 65g of carbohydrates per meal with 3 meals/day). | 4 days | Immediate | No significant change in empathy levels. | The Jefferson Scale of Physician Empathy: Student Version; Post-activity Student Questionnaire, group disscussion | Empathy levels were not affected by the activity. Empathy comparisons revealed no statistically significant difference. | "Recognizing the correlation between physician empathy levels and patient care outcomes is critical to the development or modification of medical school curricula. Although other studies, such as the one performed by Clore and Jeffrey in which medical students assumed the role of a disabled patient, have suggested that role-playing activities similar to those employed in this study should have a significant effect on empathy levels, we believe that our sample size restriction and lack of longitudinal follow-up limited the significance of our results. Large-scale longitudinal studies should be conducted to evaluate the effects of simulated patient-role activities on maintaining or improving empathy levels in medical students and to explore alternative measures and activities to enhance the medical school curriculum and to train more compassionate, effective physicians." | DelPrete A, Giordano C, Castiglioni A, et al. Medical Students’ Attitudes Toward Non-Adherent Patients Before and After a Simulated Patient-Role Activity and Small-Group Discussion: Revisited. Cureus 2016; 8: e576. | ||||||||
23 | 19 | (Evans et al., 2015) | Qualitative study | 2015 | Australia | Second-year nursing students | Examine and evaluate whether students’ participation in a simulated auditory hallucination will increase their understanding and knowledge about psychosis and auditory hallucinations. | 256 | - | Auditory hallucinations | A mini lecture was provided along with role-play during simulated auditory hallucination, in a cohort of undergraduate nursing students. The recording consisted of simulated sounds of hostile and demeaning voices, showing what it may be like for individuals who have auditory hallucinations. For example, the recording was loud at times, telling the listener that they were a ‘loser’ and ‘would not get the job’. The tone was then changed to a whisper, saying that the listener was a ‘joke’, and finally to laughter and a command to the listener to ‘open the window’, along with other surreal sounds, messages and voices. | - | prior/post | A greater understanding of the nature of auditory hallucinations, and empathy for people experiencing them. Reported increased confidence in the ability to be able to understand and more appropriately assist someone experiencing auditory hallucinations. | Quasi-experimental pre-post matched-design questionnaires, | Increased their overall understanding of auditory hallucinations from the pre/post-questionnaires with statistically-significant differences in participants’ perceptions in post-questions. Participants understood the concept of self-destructive behaviour; greater understanding of auditory hallucinations and the effect that they may have on a person experiencing them following the simulation. Reported greater self-confidence in caring for a person experiencing an auditory hallucination and greater empathy towards people experiencing hallucinations. | "The results confirmed that students’ knowledge of psychosis and hallucination increased following the teaching session and simulation is a useful tool to prepare students for clinical placements in mental health practice. The participants gained insight through their partici-pation in the iPod simulation. The participants described an insider’s view, relating how important it was to be able to ‘understand and experience the voices’. Students demonstrated a change in attitude, believing they now can develop a significant understanding relationship with those who experience auditory hallucinations. They were able to explain new insights into the consumers’ world and became more empathetic. Wasylko and Stickley (2003) discussed students’ difficulty in determining the manifestation of empathy, which occurs from exposure to consumer experience through drama or simulation. Yet participants were able to describe the importance of this learning exercise as a part of their mental health clinical preparation. The iPod simulation of auditory hallucination gave a brief glimpse of the consumers’ reality and promoted a sense of change in students’ perception, ultimately leading to a positive clinical placement experience." | Evans J, Webster S, Gallagher S, et al. Simulation in Nursing Education: IPod As a Teaching Tool for Undergraduate Nurses. Issues Ment Health Nurs 2015; 36: 505–512. | ||||||||
24 | 20 | (Evans et al., 2005) | Qualitative study | 2005 | USA | Pharmacy students | Evaluate whether the Geriatric Medication Game increases understanding, awareness, and empathy towards geriatric patients and the challenges they encounter in our health care system, especially as those challenges relate to medication use. | 102 (96) | Role play, geriatric patients, pharmacy education, medication | Old age | In the Geriatric Medication Game, students “role-play” an older adult with assigned physical, financial, or psychological issues, navigate the health care system, and execute different tasks (eg, reciting their medication list, accurately filling a weekly pill box). Students must pay (using “health credits”) for health services based on their financial status. The simulated experience includes 6 stations: physician’s office, nurse practitioner visit, pharmacy, tests and benefits, “home,” and activities. Cards drawn at a station send students to another station, ask them to perform an activity, or add a new condition or medication. Station facilitators mimic real health care providers and exhibit different amounts of empathy or caring. An additional facilitator, visits students while they wait in line for a station and makes positive or negative changes in their health and well-being (eg, add a new medication, remove a disability). | 1-1,5 h | Immediate | Increased understanding, awareness, and empathy towards geriatric patients. Increased perception that older patients have a difficult time taking their medications. Greater understanding of geriatric patients and increased empathy for these patients in the health care system. Increased their awareness of problems encountered by geriatric patients in the health care system. More appropriate communication with geriatric patients and way to help them maneuver throughout the health care system. | Pretest and posttest questionnaire, reflection | Nearly 75% of the students stated increased their awareness of problems encountered by geriatric patients. Only 1% reported no increase in awareness. 80% stated greatly increased empathy toward geriatric patients in the health care and pharmacy systems. 75% reported improved understanding of possible way to help geriatric patients in our country’s health care and pharmacy systems. | "The Geriatric Medication Game serves as a resource for increasing pharmacy students’ awareness of the perceptions and experiences of geriatric patients. The Geriatric Medication Game increased student empathy and understanding of geriatric patients, which may help them realize their responsibility for improving the delivery of pharmaceutical care to these patients. Central to this delivery are improved communication skills and reflecting empathy and patience when interacting with older patients. Other health care professionals would likely benefit from including the game in their professional development programs. The Geriatric Medication Game focuses on the application of medications within the health care system, but also underscores the interdependency of health care professions." | Evans S, Lombardo M, Belgeri M, et al. The geriatric medication game in pharmacy education. Am J Pharm Educ 2005; 69: 304–310. | ||||||||
25 | 21 | (Everson et al., 2015) | Qualitative study | 2015 | Australia | Second-year nursing students | Report on changes in nursing students' empathy towards culturally and linguistically diverse patients following exposure to an immersive 3D cultural simulation. | 460 | - | Cultural empathy | During an introductory briefing is provided and students are asked to imagine that they have been travelling in a developing country, have become acutely unwell, and as a result have been admitted to a small community hospital. Students then lie on a bed and view a 10‐minute 3D video of an unfolding scene in a hospital ward. The environment, language, and clinical practices include an amalgamation of cultural behaviours, symbols and metaphors incongruent with Anglo‐Celtic Australian culture. As the scene unfolds students are also exposed to a range of unfamiliar smells and tactile stimuli. | 10 min | Immediate | Increased empathy. | The Modified Kiersma‐Chen Empathy Scale (+ the Valuing Affective Empathy subscal) | Enhanced empathy towards people undergoing the same or similar type of experience, for example CALD patients undergoing health care in an Australian context. | "The immersive 3D simulation had a positive impact on nursing students' empathy levels in regards to culturally and linguistically diverse groups. Research with other cohorts and in other contexts is required to further explore the impact of this educational approach. The results from this study attest to the potential for immersive 3D cultural simulations to positively impact empathy levels in nursing students, particularly in regards to CALD patient groups. This is encouraging as the 3D cultural simulation required limited resources and staffing and provided a positive learning experience for students. However, there is a need for further testing of this cultural simulation approach with other health professional students and in other contexts to determine generalisability of results. Finally, as scale development is an iterative process further research that uses the MKCES is also warranted." | Everson N, Levett-Jones T, Lapkin S, et al. Measuring the impact of a 3D simulation experience on nursing studnets’ cultural emoathy using a modified version of the Kiersma-Chen Empathy Scale. J Clin Nurs 2015; 24: 2849–2858. | ||||||||
26 | 22 | (Eymard et al., 2010) | Qualitative study | 2010 | USA | Second-year nursing students | Increase nursing students’ and health care participants’ knowledge and empathy in regard to normal changes associated with aging and several disease processes, such as chronic obstructive pulmonary disease. | 42 | - | Old age | Participants visited 4 simulation stations each consisting of a table including simulation equipment and necessary props, such as canes and walkers, allowing participants to ‘‘take a walk’’ and experience physical ailments sometimes associated with older adults. A physical limitation suit allowed participants to experience joint stiffness and limited mobility. | 3h | Journals throughout the study | Increased knowledge and empathy while serving in teaching roles, experience in serving in the nurse educator role while also increasing knowledge of older adults. Anxiety concerning educating health care employees was initially expressed. Shared a sense of accomplishment at the completion of the project increased knowledge of older adults. | Informal conversations with students and examination of their journals | Students recognized empathy within themselves and in the participants. | "Student participants expressed an increase in empathy and knowledge with regard to older adults." | Eymard AS, Crawford BD, Keller TM. “Take a Walk in My Shoes”: Nursing Students Take a Walk in Older Adults’ Shoes to Increase Knowledge and Empathy. Geriatr Nurs (Minneap) 2010; 31: 137–141. | ||||||||
27 | 23 | (Gallagher, 2017) | Pragmatic trial/ thematic-analysis | 2017 | UK | Second & third-year nursing students | Report elements of findings from a thematic analysis of 6 focus groups with care‐recipients or “simulants” and student nurses (care‐givers) who participated in the immersive simulation intervention. | 48 | - | Old age | Simulants were given time to assume the profile of an older person receiving residential care. Props were provided to simulate sensory and physical deficits, i.e. ear plugs, walking aids, wheelchairs and incontinence aids. They were then brought together with student nurses where they shared their simulant profile. | 24h | Throughout (1h during Day 1), immediate after | Newfound appreciation that even if a care‐giver is in the next room or outside the toilet door, to the recipient they have simply “disappeared” or “gone” and for all they know may be too far away to help. Deeper appreciation in simulants and student nurses of the need to be constantly aware of the vulnerability and dignity of those they care for and of what enables and diminishes it. The ability to make meaningful choices, both large and small. Appreciation of how one's identity and value may be diminished as a result of a care experience. | Discussion, focus group | Referred to feelings of dependency, fear of abandonment (time‐sensitive needs required the assistance of care‐givers who were not currently in the room) and experiencing a lack of control (being pushed in a wheelchair). Quite shaken when everyday tasks participants took for granted suddenly required them to enlist the assistance of others. Feared that help might not come in time and they might have no means by which to call for help. | "Findings suggest that the immersive simulation experience had a powerful immediate impact as participants described epiphanous insights relating to their care experiences. It is suggested that reflecting on and recording epiphanous events has the potential to sustain ethical care practices." | Gallagher A, Peacock M, Zasada M, et al. Care-givers’ reflections on an ethics education immersive simulation care experience: A series of epiphanous events. Nurs Inq 2017; 24: 1–10. | ||||||||
28 | 24 | (Hales et al., 2018) | Qualitative study | 2018 | New Zealand | Regustered nurses & registered physiotherapist | Explore whether wearing a simulation suit influenced the attitudes and perceptions of health professionals toward persons living with extreme obesity. | 7 | Qualitative research, obesity, severe, staff attitude, simulation training | Obesity | Participants wore a suit simulating the shape and size of a person with extreme obesity and engaged in activities such as taking public transport or visiting a café. The suit weighed approximately 7.5 kg (20 lb) and simulated the shape and size of a person with extreme obesity, although not the actual weight. Participants were asked to engage in activities such as walking up and down stairs, tying shoelaces, taking public transport, visiting a café, or going food shopping in a large metropolitan supermarket. | 2h-3h | Immediate pre/post | Personal attitudes were found to be less judgmental and more empathetic. Participants related to how being a larger size made movement more uncomfortable, slower, and tiring. Deeper understanding of how shape and size impact activities of daily living and physical interactions with the environment. Greater appreciation of how people with extreme obesity may become socially isolated and withdrawn from society. | Audiotaped, semistructured interviews, 5 open-ended questions questionnaire | Even with existing awareness, participants had not expected the extent of the physical challenges they experienced when wearing the simulation suit. Reflected a new appreciation for the mobility challenges and he social stigma that people with extreme obesity face. Social stigma also were reported to occur within the hospital and were enacted by health professionals. Reported intentions to be less judgmental and more empathetic and understanding of the specific needs of people with obesity. | "Following the exercise, personal attitudes were found to be less judgmental and more empathetic. Using a simulation suit may increase awareness among health professionals regarding issues facing persons with obesity and may be a positive influence on diffusing weight stigma and bias in health care settings, particularly in the area of wound prevention and management where excess weight often requires additional nursing care that may exacerbate existing biases. In this study, wearing a simulation suit enabled participants to experience, albeit briefly, a pseudo lived experience of people with extreme obesity, contributing to a better understanding of the physical and social challenges that may be faced daily by persons with excessive weight. Participants experienced physical and social impacts that had not been anticipated for the short period of time they wore the suit and reported intentions to be more empathetic regarding the needs of people with obesity. Currently, the fact that simulation suits may be rented or purchased with no guidance as to their ethical use or the physical challenges that may be encountered by the wearer is concerning. The authors advise simulation suit use should be undertaken with caution in health care settings, and they propose ethical guidance needs to be developed in conjunction with further research to explore the risks and mitigation of increasing unintended weight bias when working with simulation suits in clinical practice and education. A paucity of research exists regarding the use of simulation suits and their impact on weight bias and stigma across all health care settings. Studies to investigate the application of simulation suits in the area of wound prevention and management and how they can reduce weight stigma and bias are warranted." | Hales C, Gray L, Russell L, et al. A qualitative study to explore the impact of simulating extreme obesity on health care professionals’ attitudes and perceptions. Ostomy Wound Manag 2018; 64: 18–24. | ||||||||
29 | 25 | (Halpin, 2014) | Quasi-experimental study | 2014 | USA | Nurses, nurse assistants, clinical staff, medical support assistants, physicians, social workers, psychologists, nonclinical staff | Evaluate the efficacy of a short aging simulation workshop toward increasing positive attitudes towards older adults among a multidisciplinary group of workshop participants using a pre-post quasiexperimental design. | 476 (341 clinical staff) | - | Old age | The SECURE Project consisted of a 22min video and a kit that includes experiential aging devices. The video prompts participants to perform everyday tasks through the use of these experiential devices in the areas of vision, audio, and dexterity. This was achieved with built in pauses in the video where participants were required to use the devices. Eyeglasses are used to simulate glaucoma, macular degeneration, stroke, cataracts, and yellowing of the lens, sentences such as ‘‘Do you know the way to the front door?’’ were played from a prerecorded supplemental video to emulate normal (10–20 decibels), mild (27–40 decibels), and moderate (41–55 decibels) auditory loss, thick gloves. Finally, participants are shown a 4min video of a poem set to music. | 45 min | Immediate pre/post | Increased positive attitudes towards older adults. | Kogan’s Attitudes Toward Old People Scale (KOP) | Positive attitude change towards older adults among various hospital staff following a short aging simulation workshop. Neutral-to-positive attitudes towards older adults were identified. | "As our aging population continues to swell, the overall patient population will increasingly deal with multiple cooccurring chronic conditions as they age, requiring interactions with both clinical and nonclinical healthcare employees. In preparation for this, identifying modes of training that are effective in increasing positive attitudes towards older adults among both clinical and nonclinical employees will only become more crucial." | Halpin SN. Evaluating the efficacy of a short aging simulation workshop for an interdisciplinary group of health-care employees at a veterans affairs medical center. Educ Gerontol 2015; 41: 207–215. | ||||||||
30 | 26 | (Halton & Cartwright, 2018) | Qualitative study | 2018 | UK | Pharmaceutical company employees | Investigate the impact of an immersive training program on pharmaceutical employees’ understanding of IBD and connection to patients, empathy, and perception of job value. | 104 (97) | Inflammatory bowel disease (IBD), human–media interaction, immersive learning, digital intervention, empathy, patient connectivity, job role, mixed methods | Inflammatory bowel disease | ‘In Their Shoes’ simulation program used a mobile application to deliver time-based tasks and challenges over 36h, supplemented with telephone role-play and ‘kit’ items to open and use. The participants read a standardized patient profile detailing basic disease state information and time since diagnosis, there was also dietary guidance. The application has an avatar which shows signs of stress and illness during the more intense narrative sections (e.g., sweating, turning red or pale). At 4 points during the experience there were live role-plays (via phone) with an actor following a specific script. Participants are given a kit of wrapped items which they keep with them during the experience, this contains 12 items which underscore challenges (e.g., blood capsule to simulate blood in stool; stool sample pot – used during nurse role-play; protective bed sheet for those participating in the optional night experience). | 36h | Immediate pre/post | Increased understanding of and empathy for the lived experience of patients with IBD. Statistically significant increases on self-rated disease understanding, self-rated connection with and advocacy for people living with IBD, and belief that job role can positively impact others (prosocial job perceptions). Central themes of how it felt to take part demonstrate significant emotional engagement, with activation of both cognitive and affective empathy, and evidence of a progression from lower order to higher order cognitive skills, moving beyond knowledge (taking on facts) to understanding (drawing conclusions). | The Toronto Empathy Questionnaire, Prosocial Job Characteristics Scale, and structured questions around IBD understanding and connection to patients | Significant increases in reported IBD understanding and connectivity to patients post-intervention statistically significant change: understanding of living with IBD (z = 7.475), understanding of physical symptoms of IBD (z = 6.197), understanding of emotional and psychological issues (z = 5.867), empathy toward people with IBD (z = 6.008), confidence talking to stakeholders about the impact of IBD on patients’ lives (z = 6.045), and connection to patients (z = 5.607). There was also an increase in perceptions of organizational innovation in its approach to patient-centered care (z = 3.687, N-Ties = 46, p<0.00025). Statistically significant increase in empathy (meddium effect size (d=0.45) and small statistically significant increase in prosocial job perceptions. | "An immersive training program, focussing on the lived experience of illness, led to significant increases in disease understanding and empathy. These findings align with other literature evaluating immersive learning and the potential for increasing knowledge, empathy and motivation. The present study offers opportunities to extend this outside of the body of work focussing on healthcare practitioners and explores the benefits of using this type of learning experience within an organizational setting. The study demonstrated that an immersive training program, focussing on the lived experience of illness, led to significant increases in disease understanding, connectivity and empathy toward patients amongst employees of a pharmaceutical company. In addition to increases in patient connection, this study was the first to demonstrate increases in prosocial job perceptions and organizational engagement in a simulation context. These findings align with other literature evaluating immersive learning and the potential for increasing empathy, motivation and connectivity through simulation experiences in both organizational and medical settings." | Halton C, Cartwright T. Walking in a Patient’s Shoes: An evaluation study of immersive learning using a digital training intervention. Front Psychol 2018; 9: 1–13. | ||||||||
31 | 27 | (Han & Brown, 2020) | Qualitative study | 2020 | USA | Caregivers | Explore experiences of caregivers of people with dementia who participated in a dementia simulation program Dementia LiveTM by using individual interviews. | 14 (10 formal) | Alzheimer’s disease, caregivers, dementia, empathy, simulation training | Dementia | Headphones with MP3 players playing noises and sounds from televisions and radios are used to confuse participants by affecting their attention level and hearing. The eyewear is used to restrict participants’ peripheral vision and gloves are used to diminish their sense of touch and fine motor skills. 4 different versions of 5 tasks are used, so none of the participants is given the same task. Examples of the daily tasks include: taking the checkbook from the purse and putting it on the table; taking Tuesday noon pill; and sorting the silverware into the tray. The experience room is set up with needed items and unneeded items for task completion. Participants’ behaviors are being observed by a trained observer who takes notes on the observation form of the manual with the list of tasks and behaviors. The list of behaviors includes: asking for help; following (following someone else and doing what he or she does); gathering (holding onto or collecting things); giving up/shutting down; an expression of negative self-image, frustration, anger, an confusion; rummaging; talking to self; and wan- dering. | 7min | 3 weeks after | More empathy and sympathy to better understand about the behaviors and feelings of people with dementia, and to use strategies that can help when working with them. | Individual interviews | Felt “confused”, “frustrated”, “scared”, “embarrassed”, and “overwhelmed”. Helped to understand better about what people with dementia would experience and feel with challenges due to dementia, and thus leading to having more empathy and sympathy toward people with dementia. Better understanding about behaviors and emotions of people with dementia, promoted the use of helpful strategies in caring for people with dementia as they personally experienced how difficult it was to complete simple tasks. The DL experience helped participants understand why certain strategies are important and needed for people with dementia. | "Dementia simulation programs such as the Dementia LiveTM may help caregivers to have more empathy, understand better about the behaviors and feelings of people with dementia, and to use strategies that can help when working with people with dementia. Further experimental research is needed to examine effectiveness of the dementia simulation program on caregivers and people with dementia. The present study found caregivers’ positive experiences in and potential benefits of a dementia simulation program on caregivers of people with dementia. Potential gains include having more empathy and sympathy toward people with dementia and better understanding about behaviors and emotions of people with dementia and promoting the use of helpful strategies when working with people with dementia. Further studies with a high-level quantitative research design such as randomized controlled trials with enough sample size and validated outcome measures are needed to measure the effectiveness of dementia simulated learning experiences on caregivers of people with dementia." | Han A, Brown D. Experiences of Caregivers in a Dementia Simulation Program. J Soc Serv Res 2020; 46: 71–80. | ||||||||
32 | 28 | (Han et al., 2019) | Qualitative study | 2019 | South Korea | Caregivers | Explore experiences of caregivers of people with dementia who participated in a Korean dementia simulation program. | 28 (12 formal) | Alzheimer’s disease, caregivers, dementia, empathy, simulation training | Dementia | Headphones with MP3 players playing noises and sounds from televisions and radios are used to confuse participants by affecting their attention level and hearing. The eyewear is used to restrict participants’ peripheral vision and gloves are used to diminish their sense of touch and fine motor skills. 4 different versions of 5 tasks are used, so none of the participants is given the same task. Examples of the daily tasks include: taking the checkbook from the purse and putting it on the table; taking Tuesday noon pill; and sorting the silverware into the tray. The experience room is set up with needed items and unneeded items for task completion. Participants’ behaviors are being observed by a trained observer who takes notes on the observation form of the manual with the list of tasks and behaviors. The list of behaviors includes: asking for help; following (following someone else and doing what he or she does); gathering (holding onto or collecting things); giving up/shutting down; an expression of negative self-image, frustration, anger, an confusion; rummaging; talking to self; and wan- dering. | 7min | ~2 weeks after | More empathy toward people with dementia, positively affected strategies, and increased awareness in possible changes due to aging and the risk of dementia. | Individual interviews | More empathy, affected care strategies positively leading to emotional and social benefits on the care dyads, and increased awareness in possible changes due to aging and the risk of dementia. Reported better understanding about the difficulties in daily life of people with dementia, and realization that living with dementia as a whole would be harder than they thought, related emotions to how people with dementia would feel in their day-to-day lives. The most commonly mentioned emotions were frustration, embarrassment, confusion, fear, the pressure/anxiety to do anything, and overall mental distress. Better understanding of the usual behaviors of people with dementia in their daily lives. Helped to realise, establish new care strategies or promote the use of them, it was to complete simple tasks during the simulation experience. Improved communication between people with dementia and caregivers. | "The present study was the first study that explored experiences of caregivers of people with dementia in a dementia simulation program in an Asian country. The present study found Korean caregivers’ positive experiences in and potential benefits of a Korean dementia simulation program on caregivers of people with dementia. The present study also demonstrated that a program developed in USA could be modified by considering Korean culture and the modified program could be beneficial to caregivers of people with dementia in South Korea. Caregivers in the other Asian countries may also benefit from participation in dementia simulation programs and modifying existing programs developed in Western countries by considering their own cultures can be one easy and useful way." | Han A, Kim T, Hong H. Experiences of caregivers of people with dementia in a Korean dementia simulation program. Dementia 2019; 0: 1–15. | ||||||||
33 | 29 | (Harris et al., 2018) | Qualitative study | 2018 | USA | Pharmacy students | Determine if an experiential activity resulted in increased empathy for patients with diabetes, comfort in counseling these patients on nutrition, and knowledge of diabetes dietary recommendations. | 140 (53) | Empathy, nutrition, patient counseling, diabetes, experiential | Diabetes | In the first week, students were asked to track their typical diet over three days, noting caloric and carbohydrate intake. In the second week, they were asked to design a three-day meal plan for a patient with diabetes that fit specific parameters (1500 calories/day, 45 g carbohydrates/meal, 15–20 g carbohydrates/snack). These parameters were selected as they would be reasonable for most patients with diabetes who also required weight loss. The meal plan had to include food quantities and recipes, along with a grocery list outlining all of the items required for preparation. In the third week, students followed the three-day meal plan and tracked data with the same means they used in the first week. | 3 days | For 1 week after | Significantly increased confidence in counseling, empathy for patients with diabetes and comfort with diabetes nutrition counseling. | The Kiersma Chen Empathy Scale, one-page reflection | Comfort in counseling on a diabetes diet increased significantly more in students completing the empathy assignment (4.7 vs 3.5; p=0.044). Knowledge improved by 9.7% (p = 0.859). Empathy for patients with diabetes improved by 6.4 points (p = 0.045). Comfort with counseling patients on a diabetes diet increased. Increased comfort in identifying carbohydrates and protein, as well as counting carbohydrates and calories. 64.5% of students in the intervention group reported a more healthy diet. Tracking of macronutrients increased to 77.2%. Most notably, students started tracking carbohydrates with a 45.2%. | "Implementation of a similar assignment could be considered for experiential rotations with nutrition counseling. Inclusion of an empathy assignment in third-year experiential rotations increased students’ comfort levels with diabetes nutrition counseling and empathy for patients with diabetes more than rotations without the assignment. Both groups of students saw similar but significant improvement in knowledge related to diabetes nutrition, and overall students found the assignment either helpful or very helpful. Implementation of a similar assignment could be considered for experiential rotations that have a nutrition counseling component." | Harris K, McCarty D, Wilson J, et al. The use of a disease state simulation assignment increased students’empathy and comfort with diabetes nutrition counseling. Curr Pharm Teach Learn 2018; 10: 1272–1279. | ||||||||
34 | 30 | (Henry et al., 2007) | Qualitative study | 2007 | USA | Nutrition and dietetics, physical therapy, and long-term care administration students | Determine if the Aging Game, adapted for use with allied health students, could yield positive results in the students’ levels of anxiety about aging and attitudes toward aging. | 156 | - | Old age | While taking on the role of an older adult with disabilities, disciplines asked to navigate various situations in simulated locations such as a grocery store, bus, a nursing facility. During this activity students were confronted with an array of struggles common to older individuals in the real world, but generally unfamiliar to those who are young and healthy. | 80 min | Immediate | Low anxiety about aging and positive attitudes toward older adults. Some more negative attitude toward older adults. Overall changes in anxiety levels and attitudes were small. Enhances understanding of older adults experience and ensured sensitisation to the older adults needs. Increase in empathy. Understanding of the meaning of others experience lead to intense immediate reactions to the experience of the game including frustration anger and withdrawal /resignation. Experienced some sense of shared suffering. | Pre/posttest questionnaires containing the Anxiety about Aging Scale (AAS) and the Aging Semantic Differential (ASD) measures | 31% showed lower anxiety levels and 39 % improved attitude scores. Reduction and anxiety about physical appearance and increase in anxiety regarding psychological concern and fear of losses. | "Overall participation in an ageing game simulation activity appeared to be beneficial two allied health students and increasing their awareness of ageing. The primary goals of the activity where for students to increase their understanding of the problems that older adults face and emerge sensitised to older adults. However, students responded differently to the experience and a variety of factors a pet related to the results of the ageing game. A short-term effect of this awareness was reflected in some increase in anxiety and less positive attitudes toward older adults - especially among the younger students. Further work is needed to optimally affect more students understanding and attitudes over the long term. efforts that might strengthen this experience are modifications to the simulation itself to include examples of positive communication with older adults. also class experiences can build from the ageing game simulation and emphasise opportunities to improve the health and abilities of older adults relative to each discipline. these activities can take many formats, such as written assignments, interaction with older adultS, and development of strategies for health promotion at any age. developing learning activities that help students understand the perspectives, beliefs, and experiences of older adults can have a positive impact on the empathetic delivery of care. Additional testing of students allowing for a longer period between the simulation and the posttest is also needed. the change is seen in the study, though minor, we're based on a very short time period. These changes may have been merely short term reactions to the simulation rather than long term indications of feelings and attitudes towards older adults. in the future, the curriculum of these allied health costs may include activities such as those described above and use of the AAS and ASD with measures of empathy at longer time intervals to determine changes and stability of changes in students’ and anxiety about ageing and attitudes towards older adults overtime." | Henry BW, Douglass C, Kostiwa IM. Effects of participation in an aging game simulation activity on the attitudes of Allied Health students toward older adults. Internet J Allied Heal Sci Pract 2007; 5: 1–9. | ||||||||
35 | 31 | (Hunter et al., 2018) | Mixed-methods study | 2018 | UK | Nursing students | Explore student nurses' attitudes towards those who are obese and whether these attitudes change following a simulated activity. | part 1 n=39 part 2 n=29 | Student nurse, attitudes, empathy, obesity, simulation | Obesity | Participants wore bariatric empathy suits while undertaking a range of everyday activities such as tying shoe laces and using public toilet facilities. | 30 min | Immediately | Recognised the complexity and emotional challenges of caring for such patients. More likely to state that obese patients would experience ridicule, low self-esteem, fatigue and depression. Expressed concerns about their ability to support this patient group and recognised the challenges in addressing issues related to obese patients. Recognised that nurses require additional physical support when caring for obese patients that may impact negatively on the patient if care was delayed. Enhanced empathetic understanding of obesity and its impact on individuals' everyday lives. | "Nurses' attitudes towards obesity and obese patients scale" (NATOOPS) questionnaire | Identified a connection between experiences of wearing the suits and the reality of living with obesity, issues of spatial awareness and limitations of the environment, perceived that living with obesity could lead to social isolation and disengagement as the effort required to mobilise and carry out everyday activities was monumental and demotivating. Demonstrated good insight into coping strategies, both adaptive and maladaptive that may be used by those who are obese. More likely to believe that obese patients need more emotional support; are more self-conscious than normal weight patients; are less likely to be self-confident and more likely to be depressed. Moreover, students perceived that obese patients are less likely to feel socially accepted and are more likely to be the subject of ridicule and are thus more likely to have a lower opinion of themselves than normal weight people. They independently challenged their pre-conceived ideas about obesity and students expressed the need for compassion and tolerance and the challenges of empowering this client group, acknowledged the impact of their pre-conceived ideas when caring for these individuals. | "Following a structured educational experience student nurses' attitudes were more positive towards obese patients. The characteristics of the educational activity that appeared to influence student nurses' attitudes was related to the “lived experience” of wearing bariatric empathy suits. This study illustrates that the use of bariatric simulation suits can be a powerful method for enabling student nurses to explore the physical, social and emotional challenges that obese patients face. Additionally it has highlighted that attitudinal change can be achieved with structured simulated educational interventions. The study also highlighted the emotional labour for nurses of caring for obese patients which suggests that more time and focus is required in the curriculum to address the needs of both obese patients and the nurses caring for them." | Hunter J, Rawlings-Anderson K, Lindsay T, et al. Exploring student nurses’ attitudes towards those who are obese and whether these attitudes change following a simulated activity. Nurse Educ Today 2018; 65: 225–231. | ||||||||
36 | 32 | (Jeong et al., 2017) | Integrated study | 2017 | South Korea | Nursing students | Identify the effects and experiences of the senior simulation applied to nursing students on those students’ attitudes toward seniors. | 70 | Senior simulation, educational program, integrated method, nurse students | Old age | Simulation clothing consisted of the simulation clothing itself as well as gloves (1 pair), glasses, earplugs (1 pair), and a walking stick. Partisipant had to experience sitting the chair, hearing the helper's explanation, reading the script; walking in the hallway, go up and down the stairs, sitting the chair; eating the snack, drinking the beverage. | 13min | Immediate, 1 week after - focus group, 2 weeks after - questionnaire. | Attitudes turned more negative after the simulation than before the simulation, but they turned significantly positive after the sharing of thoughts with others, with the final effect of enhancing attitudes. Enhancement of participants’ understanding of seniors, a regret of past actions, and a consideration for their own later years, along with the will of the nursing students in their future nursing, as they mentioned that this experience had been positive. | Semantic differential scale, Attitudes toward seniors questionnaire, In-depth interviews | The attitudes toward seniors became significantly more negative (p<.001), more positive after sharing feelings in comparison to immediately after the program (p<.001), and conclusively more positive after sharing feelings than before the program (p=.022). Allowed the realization that for seniors, movement is difficult and they fatigue easily. Reflections included the will to give kind care to seniors, the will to help seniors positively, and the will to prepare themselves for their own old age. | "The research results, with respect to the qualitative measurement, demonstrated differences according to the times at which the measurements were made. Therefore, in-depth interviews should be conducted both before and after the program as well as after the internalization of the experience, identifying whether changes in the attitudinal scores with respect to the actual quantitative measurements correspond to the psychological changes at the same points in time." | Jeong HS, Lee Y, Kwon H. Effects of senior simulation program for nursing students: An integrated study in South Korea. Eurasia J Math Sci Technol Educ 2017; 13: 4437–4447. | ||||||||
37 | 33 | (Johnson et al., 2018) | Descriptive study | 2018 | USA | Doctor of Audiology students | Describe an experiential learning curriculum used in the Doctor of Audiology program in the Department of Communication Sciences and Disorders at the University of Oklahoma Health Sciences Center (OUHSC) that involves didactic lectures and aging simulations that aim to transform knowledge and active experience into patient-centered, empathetic counseling skills and strategies to use with older adults having hearing loss. | - | Counseling, experiential learning, aging simulation | Old age | Person wore the GERontological Test Suit to simulate physical conditions experienced with aging: opacity of the lens (e.g., goggles to simulate cataracts), narrowing of the visual field (e.g., side blinders), high-frequency sensorineural hearing loss (e.g., earmuffs), loss of head mobility (e.g., neck brace), stiffness in the joints (e.g., elbow and knee restraints), loss of strength (e.g., wrist, ankle weights), reduced ability to grip objects (e.g., special gloves), and loss of motor coordination (e.g., shift in the center of gravity with weight vest). Instructions for participants involved walking to places and completing typical daily tasks. The Simulation of Eye Disease Glasses Kit (aforementioned ocular disorders) instructions were: “While wearing earplugs and simulation glasses, walk the same course as for station/activity 1; experience each of the ocular disorders by periodically switching goggles throughout the activity so that each team member has an opportunity to experience all of the visual disabilities.” The Hemiparesis Simulator consisted of an eye patch, earplug, arm sling, leg brace and weight, and cane. The instructions for participants were: “While wearing the hemiparesis kit, walk around the allied health building and then try to tie your shoes, heat up a cup of water in the microwave oven in the student lounge, and then attempt to change a battery in a hearing aid.” Tape, plastic gloves, cotton, uncooked popcorn, popsicle sticks, playing cards, poker chips, pen, paper, hearing aids, and batteries were used to simulate peripheral neuropathy and arthritis. The Tremor Kit consists of two (small and large) sets of special gloves and a variable control unit that delivered a range of tremor severity via electric pulses. Patients could simulate tremor during the completion of tasks in case the Tremor Kit was not available. The instructions were, “While wearing the gloves in the Tremor Kit, try to change the battery in a hearing aid; shuffle a deck of playing cards, deal a hand of poker, pick up a poker chip, and sign your name. Next, wrap all of your knuckles with scotch tape, put the plastic gloves on (one with cotton or uncooked rice in the finger tips), and slide a popsicle stick into the glove to stiffen your pointer finger, and then repeat the above tasks.” | 75 min | Immediate | - | Questions for Reflective Observation Writing Assignment | - | "The purpose of this article was to describe the use of experiential learning in the development of a curriculum that aims to sensitize Doctor of Audiology students to the needs of their elderly patients. We described an aging simulation activity in which students experience cumulative aging, ocular disorders/dual or multisensory impairments, hemiparesis, and tremors/manual dexterity issues. In addition, readers are provided with ideas about how the stages of experiential learning (i.e., concrete experience, reflective observation, abstract conceptualization, and active experimentation) can help transform students' experiences into effective counseling skills for use with elderly patients." | Johnson CE, Jilla AM, Danhauer JL. Didactic Content and Experiential Aging Simulation for Developing Patient-Centered Strategies and Empathy for Older Adults. Semin Hear 2018; 39: 74–82. | ||||||||
38 | 34 | (Juniat et al., 2019) | Qualitative study | 2019 | UK | Second-year medical students | Describe a set of low-vision simulation activities where medical students experience the challenges of daily activities faced by such patients. | 252 | Simulation, visual impairment, sim-specs | Visual impairment | Students made tea and filled dosette boxes using low-vision simulation spectacle (Sim-specs) simulating central visual loss (age-related macular degeneration) and navigated using Sim-specs simulating peripheral visual loss (glaucoma). Facilitators recorded errors made for each task: Task 1 – fine motor task: making tea (AMD Sim-specs). Students were asked to put tea bag into a mug, pour out cold water from kettle (pre-filled by facilitator), remove tea bag into bin, and pour one teaspoon of sugar into the tea. Task 2 – fine motor task: filling a dosette box with medications for 3 days (AMD Sim-specs). Students were asked to read instruc- tions, open dosette box lids, fill compartments with ‘pills’ according to instructions, and close dosette box lids. Task 3 – navigation task: washing hands at sink (glaucoma Sim-specs). Each student under simulation was accompanied by an instructor to act as a sight guide to ensure safety. Students were asked to navigate to the sink (a distance of 10 m), wash and dry their hands, and to return to their starting point. | 20 min | Demonstrated that it is easier to carry out tasks that they are familiar with or which are set in known environments. Participants were able to learn from the experience to suggest ways of adapting their approach to patients with visual impairment. Increased understanding of the challenges faced by patients with visual impairment. Appreciated that low vision had different implications for the individuals, and that some tasks would be more difficult than others based on the condition and the task at hand. | Questionnaires to grade the tasks’ difficulty on a 4-point Likert-type scale; Focus group Simulation Project Questionnaire, recorded throughts for 2 questions. | Highest average number of errors made was for dosette box task (0.70 error), followed by navigation (0.59), then making tea task (0.34). Demonstrated learning in recognising the challenges of VI and adapted their approach to patients, demonstrated that it is easier to carry out tasks that they are familiar with or which are set in known environments. Suggested ways of adapting their approach to patients with visual impairment. | "Simulation activities are valuable additions to the undergraduate curriculum. Such activities can potentially enable greater empathy for our visually impaired patients. Simulation teaching is a useful tool in medical education. The latter cannot be limited to the provision of medical knowledge. Other skills such as empathy are important. Simple simulation activities can be used by medical students to better appreciate the challenges of living with visual impairment, and we would like to roll out simulation teaching as a regular session. In addition, in a health care environment, this form of teaching should be disseminated to a wider audience range, for example, to administration staff involved in health care, in order to help improve patient experience at the hospital and in the community. The findings may also eventually be used as a basis for planning support services around the difficulty of the tasks." | Juniat V, Bourkiza R, Das A, et al. Understanding Visual Impairment and Its Impact on Patients: A Simulation-Based Training in Undergraduate Medical Education. J Med Educ Curric Dev 2019; 6: 1–7. | |||||||||
39 | 35 | (Karlowicz & Palmer, 2006) | Descriptive study | 2006 | USA | Senior baccalaureate nursing students | Faculty devised and experiential learning activity intended to recreate challenges and emotions experienced by incontinent disabled clients to help baccalaureate nursing students develop the affective behaviours, engender empathy for disabled clients with UI as well as promote proactive approach to nursing management of UI, needed to effectively care for the patient with UI. | - | - | Disability + urinary Incontinence | Wearing the undergarments dry and wet, while being confined to a wheelchair site, promoted empathy for patients with bladder control problems. During the course of the activity students assumed the roles of both an individual with a physical disability (for example, hemiplegia, paraplegia, quadriplegia, post amputation, etc.), as well as that of the caregiver partner (each role for a 6h period during walking hours). Partners were expected to be with the individual assuming a physical disability during the entire time that the role was assumed. They were responsible for assuring the safety of the individual assuming the disabled role and providing whatever assistance was required as with the family member of the individual with a disability. During the time that they were engaged in the simulation, the students were encouraged to go about their daily routine in the community. While assuming the role of an individual with a physical disability, students were required to wear an adult disposable incontinence product “dry” for 5.5 hours of the experience and “wet” during the last 30 min (naturally/with 150cc of warm tap water). Students were encouraged to visit a local drug or medical supply store and choose a product to wear. | 6h | unknown | Increased empathy and understanding of embedded patient point of view. | 3-5 page reflective-descroptive paper | Given perception of what people with bladder incontinence problems go through, realised that people with bladder dysfunction might be easily embarrassed, created a very empathetic understanding of individuals with similar problems where once there was just a cursory acknowledgement and increased awareness about issues in bowel and bladder management. Showed how uncomfortable is staying in wet underwear, realised the patients should be checked at least every two hours while turning them. Reminded how important it is that nurses and other caregivers be close attention to the bladder habits of disabled adults and work on bladder training. | "The disability incontinence experiential learning activity has been a required component of the baccalaureate curriculum for over 10 years. In that time, only a handful of students have formally requested to opt out of the experience. One was granted permission because she already had an understanding of UI due to a personal health issue. The other students eventually decided to participate in the experience after discussion and counselling by faculty. In these instances, we alive their fears by helping them to understand that the concerns they have about the experiences are precisely the feelings, attitudes, and believes we want them to confront. We further explained to the students that their ability to be patient advocates and provide quality nursing care depends upon them understanding these issues from the patient’s point-of-view. Faculty members remain amazed by the powerful impact the experience has on students’ attitudes regarding the management of UI. The disability continent's experience appears to engender empathy for patients with UI by raising students’ awareness about the effects of UI on the individual psychosocial well-being. It also seems to promote a change in attitude regarding the nurses’ responsibility in continents care that is evident in their efforts to apply blood and management strategies in the clinical setting. Perhaps more gratifying are the comments from alumni who considered this activity one of the most memorable and important learning experiences or the Baccalaureate education - one that continues to influence their practise of nursing long after graduation." | Karlowicz KA, Palmer KL. Engendering student empathy for disabled clients with urinary incontinence through experiential learning. Urol Nurs Off J Am Urol Assoc Allied 2006; 26: 373–378. | ||||||||
40 | 36 | (Kerr et al., 2015) | Longitudinal descriptive study | 2015 | USA | Third-year pharmacy students | Assess the impact of a 6-week patient/provider interaction simulation on empathy and self-efficacy levels of diabetes management skills in third-year pharmacy students. | 54 (48) | Diabetes, self-efficacy, empathy, student pharmacist | Diabetes | The patient/provider interaction simulation activity randomly paired students, with one assigned the role of patient and the other, clinical pharmacist provider. They assumed the assigned role for 3 consecutive weeks then switched roles and partners to extend interactions with other students in the course. Patients were provided with a backpack that included all diabetes testing supplies, empathy exercise supplies, medications (including oral and injectable placebo), and a background patient history data form. During the 3 weeks students assumed the patient role, they were encouraged to follow an appropriate diet that met all nutritional requirements for patients with diabetes, to take prescribed (placebo) medications, to test blood sugars at least twice per day or per the recommendation of their provider, to experience simulated disease progression, and to complete sampled empathy exercises. | 6 week | Immediate | Better understood what a patient with diabetes, or any other chronic health condition, had to go through. Improved self-efficacy in diabetes management and empathy toward patients. Participants more likely to empathize with patients when recommending therapy. | The Jefferson Scale of Empathy (JSE) and a self-efficacy survey | Improved empathy and self-efficacy levels in third-year pharmacy students. The total scores on the JSE increased to 123 (10.1) (p,0.001). Showed a significant improvement in self-efficacy scores with an increase in the overall average to 4.3 (p,0.001). Benefit from writing SOAP notes and correlating success with recommendation acceptances and improvement in these skills. Felt more comfortable with their interviewing skills after the weekly appointments. | "The results of this study suggest that the patient/provider interaction activity used in a diabetes elective course is an effective way to help improve students’ self-efficacy in disease state management and their empathy towards patients. Similar methods or the incorporations of additional disease states in the exercise could be used to further improve student learning and empathy toward patients." | Kerr JL, Stahnke AM, Behnen EM. Assessing empathy and self-efficacy levels of pharmacy students in an elective diabetes management course. Am J Pharm Educ 2015; 79: 1–7. | ||||||||
41 | 37 | (Kerr, 2015) | Qualitative study | 2015 | USA | Junior level nursing students | Explore the use of simulation to augment didactic content on the care of patients with ostomies within a BSN nursing curriculum and explore the students’ perception of the impact that participating in the simulation would have on their preparation to care for patients who have undergone ostomy surgery. | 33 (29) | - | Ostomy care | Each student identified and marked a potential stoma site on a peer using a black, felt- tipped marker. An ostomy appliance of choice (fecal or urinary) was applied to the site and adhered to the skin and the adhesive backing of the appliance. Fecal appliances were prefilled with an approximately one-half cup of cooked wheat cereal mixed with cocoa powder and placed on the site to simulate a lower left quadrant colostomy. Urostomy appliances were prefilled with an approximately one-half cup of prepared instant lemonade and placed on the site to simulate a lower right quadrant ileal conduit. Students wore and managed the appliance for 24h and had the opportunity to sleep with the appliance in place, empty the contents of the appliance into the toilet on awakening the next morning, shower or bathe with the empty appliance in place, conceal the empty appliance under clothes throughout the day in their dorms and while attending classes on campus and remove and dispose of the appliance at the end of the 24hperiod. | 24h | Within 1 week | Affirmed the value of participating in the simulation. | 3-4 page reflection | negative impact of activities of daily living, which included difficulty managing the appliance; dressing to conceal the appliance while on campus and while exercising in the university athletic center; finding a comfortable position for sleep, while protecting the appliance to address concerns about potential leakage; and drying the appliance adequately after showering before getting dressed for class. Partici- pants described feeling “different,” “embarrassed,” “judged,” and “like an outcast.” Feeling “nervous” was common among the group and centered on anxiety over whether the appliance would fall off or whether the appliance could be successfully concealed under clothing while the student was on campus or in class. One participant described their experience of interacting with a significant other and shared feeling “less intimate” because of the presence of the pouch. Most of the participants stated that the pouch made them feel “bigger” or “like a boy” and described their concern that others would judge them as being overweight. Others commented that they experienced a limitation in clothing options and a “loss of fashion” in dressing to conceal the appliance, helped the participants to gain insight into the wide variety of topics for which a new ostomy patient needs to be educated to be able to cope with and adapt to having an ostomy. Identified understanding the importance of preoperative site marking, as well as the potential benefits to new ostomy patients of being visited by a patient who had already received an ostomy or by a WOCN before discharge from the hospital. Gained insight about (a) the importance of making sure that patients understood the reason for and normal function of the ostomy, (b) being able to share personal experiences regarding the effectiveness of the stoma wafer adhesive backing, (c) being able to share tips about how to manage and change the appliance, care for peristomal skin, and cope with any odors that might occur, (d) ideas for how to dress for comfort, function, and to conceal the appliance, (e) being able to share strategies for maintaining exercise and favorite activities, (f) the importance of being able to share resources for supplies and support with an ostomy patient, and (g) understanding the need to facilitate and listen to patients’ concerns about the impact on their sexual functioning and intimate relationships of having an ostomy. | "Each participant affirmed the value of the experience. Suggestions for future research studies are discussed. No conclusions can made as to whether the use of this simulation will result in knowledge and skills that improve the quality of care ostomy patients receive after the students graduate and enter practice." | Kerr N. Ostomate-for-a-day: A novel pedagogy for teaching ostomy care to baccalaureate nursing students. J Nurs Educ 2015; 54: 445–449. | ||||||||
42 | 38 | (Kidd et al., 2015) | Mixed-methods study | 2015 | USA | Nursing students | Change attitudes and decrease stigma. | 78 | - | Auditory hallucinations | Students used mp3 players to listen to an audio simulation while simultaneously engaging in activities requiring focus and concentration. While listening to the simulation, students performed a mental status exam, completed word and number search puzzles, or read a scholarly article or textbook chapter. | - | Immediate | Increased comfort being around persons hearing voices, but less likely to acknowledge individual behavior as indicative of recovery. Developed more empathy. | The Attitude toward Mental Ill- ness Questionnaire (AMIQ) and open-ended questions about the experience | Increased patience, tolerance, understanding, and empathy among participants. Reported slightly greater comfort post simulation about John being a coworker or social companion and increased expectations that John would have more negative career, marital, and legal outcomes. Demonstrated the students’ predictions of changes in their own behavior, such as being more patient, more tolerant, more considerate, more empathetic, more understanding, and becoming more knowledgeable about the experience of patients. Experiened feeling overwhelmed, anxious, spooked, scared, distressed, and debilitated. | "This study adds to the body of literature, documenting that simulation of auditory hallucinations used as a sole experiential strategy may have the opposite effect of the desired outcome of decreasing stigma in the participant. The simulation may be perceived as a traumatic experience by some, with accompanying negative emotions and desire for greater social distance from those who hear voices. Participants also may emerge from the simulation with the sense that persons who hear distressing voices are so disabled by this symptom that they cannot function well in relationships and career settings. Although nursing students gain understanding and empathy for the experience of hearing voices, filmed contact, guest lectures by persons with mental illness, and personal contact achieved through clinical interactions may be more likely to decrease stigma. An even more important, albeit serendipitous, finding of this study was what faculty learned about the importance of being mindful in the planning and implementation of simulations. Self-reflection by students and faculty may be even more instrumental in helping to decrease stigma. Although it is vital to teach nursing students the principles of care for the acutely mentally ill, too much focus on illness and its symptoms—without equal time and attention focused on recovery—may inadvertently contribute to stigma building instead of stigma busting. Faculty practicing in acute or chronic settings need to reflect on their own subtle attitudes and biases, as these will filter through to students. If faculty emphasizes illness rather than integrates recovery principles, students will incorporate a bias towards illness and chronicity. To present a fair, genuine, and comprehensive portrait of the individual living with and recovering from a serious mental illness (including hearing voices) to our nursing students, a mindful balance is required." | Kidd LI, Tusaie KR, Morgan KI, et al. Mindful teaching practice: Lessons learned through a hearing voices simulation. Issues Ment Health Nurs 2015; 36: 112–117. | ||||||||
43 | 39 | (Kimzey et al., 2020) | Mixed-methods study | 2020 | USA | Nursing students | Determine the effects of dementia simulation on nursing students’ dementia knowledge and empathy for people living with dementia. | 55 | - | Dementia | Students donned glasses with modified lenses (simulate visual field distortion). Headphones played background noise interspersed with random startling sounds to represent the inability to process the meaning of different noises. Students wore work gloves covering plastic gloves imitating decreased peripheral sensation and processing of tactile input. Once students were equipped with the simulation gear, they were given verbal instructions to complete 5 simple tasks: counting out 37 cents from a change purse, feeding the dog, sorting plastic utensils into a container, and taking out a morning dose of medication from a weekly pill container. | 7 min | Immediate? | Distress, empathic imagination, and cognitive empathy were significantely improved. Provided concrete examples of how they would support and provide patient- centered care for people with dementia. | Demographic questionnaire, The Dementia Knowledge Assessment Tool Version 2 (DKAT2), The Comprehensive State Empathy Scale (CSES) | Verbalized uncomfortable feelings indicating distress. Empathic imagination was evident by descriptions of what it would be like to have dementia, what the person living with dementia is experiencing, and a comparison of their current life to the life of someone living with dementia. Recommendations for caring for a person with dementia implied helping motivation or showing interest in getting involved or helping. Loss of cognition, physical limitations, dependency and the impact on daily life were recognized. | "This study adds to the understanding of teaching and learning about dementia care and highlights the contributions a 7min simulation made to improve empathy. The dementia simulation enabled students to experience for themselves the physical and mental challenges those with dementia face. Dementia education should empower nursing students to appreciate the needs of people with dementia and their caregivers, support them in care, and provide person-centered care." | Kimzey M, Patterson J, Mastel-Smith B. Effects of Simulation on Nursing Students’ Dementia Knowledge and Empathy: A Mixed Method Study. Issues Ment Health Nurs 2020; 0: 1–6. | ||||||||
44 | 40 | (Kuster, 1993) | Reflective study | 1993 | USA | Introduction to communication disorders students | Possibly prompt others to learn first hand by repeating their experiment, helping anyone around children with a hearing loss understand the problems and frustration these children encounter. | 84 | - | Deafness | Students purchased ear plugs producing approximately 35 db HL conductive hearing loss (similar with otitis media/serious carumen buildup in the ear canals) and continued with their day. | 1 day | none | Experienced huge headache, sore neck and tired eyes, felt relief of background sound being back. Realisation of not knowing first thing about the disability. Learned importance of hearing for understanding and being aware of the environment. | Reflective paper | Easier to communicate one on one, easier to understand if they were close by and looking directly at them.When distance was added normal speech could no longer be heard. persons own voice could not be heard very well and felt like person was shouting, disadvantaged with performance at school, hard to concentrate. Difficult to follow the piano in keeping tune - everything was distorted. Could not perform multitasking as watching the TV and browsing for newspaper or mail at the same time. Change the relationship with friends and family - people grew impatient. Felt isolated from the world and everyone. Day was filled with frustration, embarrassment, anger depression and crabbiness. By the end of the day felt emotionally drained and lonely, wanted to be left alone. | - | Kuster JM. Experiencing a Day of Conductive Hearing Loss. J Sch Health 1993; 63: 235–237. | ||||||||
45 | 41 | (Latham et al., 2012) | Qualitative study | 2012 | Canada | First-year medical students | Anticipated that psoriasis would be perceived by entry-level medical students as having a low burden on the patient relative to other common medical conditions, and the exercise would change their perception of the effect of psoriasis on quality of life. | 61 | Disease burden, empathy, medical education, morbidity, psoriasis, quality of life, skin disease | Psoriasis | The adhesive side of the psoriasis tattoo was applied to the skin. The tattoo was designed to last for up to several days, but it could be easily removed by gently washing the area of application with soap and water. | 24h | Following day | Perception of the mental and physical impact of both psoriasis and eczema increased significantly. Elicited feelings of embarrassment and self-consciousness. | Pre-temporary tattoo exercise questionnaire, Post-temporary tattoo exercise questionnaire | The perception of the mental impact of both depression (mean = 91.4, P = .0001) and cancer (mean = 79.0, P = .03) was significantly lower. Reported that being somewhat embarrassed (mean = 30.8), annoyed (mean = 22.2), or bothered by the appearance (mean = 29.9) of the tattoo. 23% reported that wearing the tattoo affected their social or leisure activities. 46% reported that wearing the tattoo affected their choice of clothing. 57.4% described being affected by the exercise (eg, feelings of self-consciousness or embarrassment). | Temporary tattoos are a novel and effective method of teaching medical students about the psychological burden of psoriasis. We believe our pilot study demonstrates that temporary tattoos can be used effectively as a novel teaching tool, and that educational interventions, such as the exercise we presented here, may be incorporated into the undergraduate medical curriculum to promote an understanding of skin disease. | Latham L, MacDonald A, Kimball AB, et al. Teaching empathy to undergraduate medical students using a temporary tattoo simulating psoriasis. J Am Acad Dermatol 2012; 67: 93–99. | ||||||||
46 | 42 | (Lee & The, 2020) | Mixed-methods open-label randomized controlled study | 2020 | Malaysia | First-year pharmacy students | Examine the impact of using an aging simulation suit on undergraduate pharmacy students’ empathy levels. | 122 (52) | Aging suit, simulation, pharmacy, empathy, polypharmacy, aging | Old age | Intervention participants donned the aging suit and performed a series of tasks, sitting down and getting up from a chair and sofa, reading and filling out a form during a healthcare clinic visit, as well as picking up an object from the floor. to simulate the physical limitations experienced by an older adult. | 10 min | After 2 weeks and after 3 months | Patient-rated empathy scores were significantly higher. Expressed difficulty to relate the decreased physical function and sensory feedback experienced by an older adult. Experienced changes in task performance. Increased awareness of some of the changes in vision. | The Jefferson Empathy Scale-Healthcare Professional Questionnaire | Did not increase participants’ self-rated empathy. Enhanced the ability of participants to understand the physical limitations and visual issues associated with aging, participants health advocacy, taught them the importance of listening, good communication, patience and respect for older adults. 3 months after the JSE-HPS scores fell back to baseline levels. Importance of learning other languages and dialects to improve their interactions with older adults, evoked a sense of respect among participants toward older adults. Participants realized that older adults face many challenges in their lives, especially in relation to medication usage, why older adults had mobility issues, especially related to walking. Effected future communication with older adults, such as speaking more slowly, using a suitable volume, and using appropriate tones. Deeper insight into both physical and emotional issues related to older adults. Described the loss of sensory feedback and could relate the difficulty. Participants lamented about the difficulty with vision caused by changes to their eyesight during their experience and had great admiration and respect for older adults who could drive and read despite these limitations. Some participants mentioned that in the future, they would make changes to their practice as a pharmacist including writing in larger fonts, speaking clearly, and smiling at older adults. | "The use of an immersive aging suit can be a useful adjunctive tool to help enhance students’ understanding of the physical limitations and visual limitations of aging. Further research is needed to understand how these limitations affect other healthcare students. In summary, with an increasing population of older adults, we feel that it is of great benefit that healthcare students can appreciate what it feels like to be an older adult. The immersive aging suit can be a useful adjunctive measure for teaching students about the physical challenges faced by older adults. However, a larger study on various healthcare students’ personalized patient care and overall health outcomes should be conducted in the future." | Lee SWH, Teh PL. “Suiting Up” to Enhance Empathy Toward Aging: A Randomized Controlled Study. Front Public Heal 2020; 8: 1–12. | ||||||||
47 | 43 | (Levett-Jones et al., 2017) | Qualitative study | 2017 | Australia | Second-year nursing students | Examine the impact of an immersive point-of-view simulation on nursing students' empathy towards people with an Acquired Brain Injury. | 390 | Empathy, disability, nursing student, point-of-view simulation, Comprehensive State Empathy Scale | Acquired Brain Injury | In the point-of-view disability simulation students worked in pairs and were randomly allocated the role of either a person with ABI or a rehabilitation nurse. The student taking on the ‘patient’ role was asked to imagine that they had an ABI as a result of a car accident three months previously. They were dressed in a hemiparesis suit that replicated the experience of dysphasia, hemianopia and hemiparesis. The ‘rehabilitation nurse’ was required to support the ‘patient’ as they dressed themselves in a jacket, pants and shoes, and then take them for a walk. During the walk they were instructed to leave the ‘patient’ alone in an area of high pedestrian traffic for 5min, before they returned to the simulation unit. The ‘rehabilitation nurse’ then assisted the ‘patient’ to pour and drink a glass of thickened fluids. | ~1h | Immediate after the simulation | High empathy scores. | The Comprehensive State Empathy Scale, group discussion | SIgnificantly higher mean empathy scores post simulation (3.75, SD = 0.66) compared to pre simulation (3.38 SD = 0.61); t (398) = 10.33, p < 0.001. However, this increase was higher for participants who assumed the role of a ‘rehabilitation nurse’ (mean = 3.86, SD = 0.62) than for those who took on the ‘patient’ role (mean = 3.64, SD = 0.68), p < 0.001. | "The results from this study attest to the potential of point-of-view simulations to positively impact nursing students' empathy towards people with a disability. Research with other vulnerable patient groups, student cohorts and in other contexts would be beneficial in taking this work forward. The results from this study are encouraging and attest to the po- tential for immersive point-of-view simulations to positively impact learners' empathy towards other vulnerable patient groups. Given the unequivocal evidence about the physiological and psychosocial impact of empathic engagement with patients, further research with other student cohorts and in other contexts would be beneficial to extend on this work. Additionally, as scale development is an iterative process further studies utilising the CSES are warranted." | Levett-Jones T, Lapkin S, Govind N, et al. Measuring the impact of a ‘point of view’ disability simulation on nursing students’ empathy using the Comprehensive State Empathy Scale. Nurse Educ Today 2017; 59: 75–81. | ||||||||
48 | 44 | (Lucchetti et al., 2017) | Mixed-methods study | 2017 | Brazil | First-year medical students | Determine the impact of two educational strategies on the topic “Geriatrics and Gerontology” (“experiencing aging” and “myths of aging”) as compared to a control group (no intervention) on the attitudes, empathy and knowledge of first year medical students. | 230 | Medical education, geriatrics, medicine, older people care | Old age | Experiencing aging (“Aging Game”): students visited 5 different stations the students simulated what it feels like to be an elderly person with several aging-related physiological and pathological impairments: walking difficulties (attachment of weights to legs and walking while negotiating obstacles placed on the floor), visual problems (glasses simulating visual impairments (e.g. cataracts and glaucoma)), hearing problems (headphones introducing background noise and cotton plugging ears). | 2h | Immediate? | Increased empathy, albeit with worsening attitude. | Attitudes towards older persons (UCLA Geriatric Attitudes Tests, Modified Maxwell-Sullivan attitudes toward the elderly scale), empathy (Modified Maxwell-Sullivan attitudes toward the elderly scale), knowledge on facts and positive view about aging (Facts about aging (Palmore-FAQ-1)), and cognitive knowledge. Questionnaires collecting sociodemographic data, Basic knowledge in geriatrics | Significant difference on the UCLA scale total (a worse general atti- tude – p = 0.001), greater negativism on the Palmore questionnaire (negative opinions about aging). Worse attitude toward elderly people on the Maxwell-Sullivan attitude scale (p = 0.007) and an improvement in empathy toward the elderly on the Maxwell-Sullivan empathy scale (p = 0.001). | Educational strategies can influence the attitudes and empathy of students, leading to different outcomes. These data highlight the importance of assessing the outcomes of educational strategies in medical teaching to ascertain in what manner (how), situations (when) and settings (where) these activities should be introduced. In conclusion, educational strategies can influence the attitudes and empathy of students differently, leading to both desirable and undesirable outcomes. These results underscore the importance of assessing educational strategies in medical teaching to ascertain in what man- ner, situations and settings these activities should be run. | Lucchetti ALG, Lucchetti G, De Oliveira IN, et al. Experiencing aging or demystifying myths? - impact of different “geriatrics and gerontology” teaching strategies in first year medical students. BMC Med Educ 2017; 17: 1–9. | ||||||||
49 | 45 | (Luig et al., 2020) | Mixed-methods study | 2020 | Canada | Family medicine residents | Assessed the course’s impact on residents’ attitudes, beliefs, and confidence with obesity counselling. | 61 | Obesity, education, medical, primary health care, evaluation study | Obesity | Residents wore an empathy suit, which simulates a body size in the obesity class. Learners experienced the incumberance of obesity spending approximately 15 min in a Smart Condo executing tasks of daily living (i.e., getting dressed, cleaning the apartment, getting out of bed, making the bed). | 15 min | Immediate | Facilitated critical reflection that enhanced professional identity development around non-judgemental and compassionate care of patients living with obesity.. | 1 page narrative reflection, the Beliefs About Obese Persons Scale (BAOP), and Attitudes Towards Obese Persons Scale (ATOP) questionnaires | Improved attitudes towards people living with obesity and improved confidence for obesity counselling. Improvement in assessing root causes of weight gain (p < .01), advising patients on treatment options (p < .05), agreeing with patients on health outcomes (p < .05), assisting patients in addressing their barriers (p < .05), counselling patients on weight gain during pregnancy, (p < .05), counseling patients on depression and anxiety (p < .01), counseling patients on iatrogenic causes of weight gain (p < .01), counseling patients who have children with obesity (p < .05), and referring patients to interdisciplinary providers for care (p < .05). Significant improvement in positive beliefs about people living with obesity. 47% felt better trained and 88% wanted to learn more. Felt more comfortable assessing root causes, advising on treatment options, agreeing with patients on goals, assisting patients in addressing barriers, counseling on weight gain during pregnancy, counseling on weight-related depression and anxiety, counseling on iatrogenic causes of weight gain, counseling patients who have children with obesity, and referring patients to inter- disciplinary healthcare providers for care. Emotionally impacted residents who did not have previous lived experience with overweight or obesity. This helped them examine their assumptions about living with obesity. Most noted surprise about how cumbersome tasks of daily living were in the empathy suit. They described feeling exhausted, breathless, afraid of not being able to get out of bed, insecure about falling, and wanting to avoid unnecessary energy expenditure. Caused feelings of shock, shame, self-consciousness, and embarrassment. Allowed to feel more empathetic toward patients, reinvestigated assumptions about the causes of obesity, management and counselling, and professional identity with regards to supporting patients, led to forming intentions to adopt more empathetic and comprehensive approaches to weight management. Described a shift in their knowledge and a re-thinking of their previously held assumptions resulting from the course reflected on the psychological impact that clinic environment or procedures, such as ill-fitting gowns or larger blood pressure cuffs, has on patients with obesity. Recognized the important role they play in helping patients understand the complex factors contributing to weight, finding realistic strategies to improve health, and supporting them throughout their efforts, Recognized the importance of contextual factors of patients’ life history and circumstances. Many highlighted learning about prevention as a crucial part of their role as physicians and the importance of beginning the conversation by asking the patient for permission to talk about weight. As a result, they felt they were able to create a respectful relationship with patients; and patients were more open to the discussion. Others emphasized the benefit of asking the patient about their story of weight gain for comprehensively assessing root causes. | "The 5AsT-MD course has the potential to increase residents’ confidence and competency in obesity prevention and management. Findings reflect the utility of the 5As to improve residents’ confidence and competency in obesity management counselling. Tailored and co-ordinated primary care is crucial to reducing obesity and improving health. 5AsT-MD has the potential as a course for increasing residents’ knowledge of obesity and its complexity, as well as their competency and confidence in engaging patients in effective obesity management. The course’ pedagogical orientation and experiential components offer a novel approach to obesity management training that stretches beyond the biomedical realm and introduces the human complexity and contextuality of living with obesity. This study illustrates how this course fostered transformative learning through engaging learners in experiences offered spaces to reflect and think about what it is like to live with obesity. Our results inform an ongoing process of further refining and disseminating the course to other institutions." | Luig T, Wicklum S, Heatherington M, et al. Improving obesity management training in family medicine: Multi-methods evaluation of the 5AsT-MD pilot course. BMC Med Educ 2020; 20: 1–11. | ||||||||
50 | 46 | (Marshall et al., 2018) | Qualitative descriptive content analysis study | 2018 | USA | Nursing students | Implement and evaluate a cost-effective, brief intervention that exposed students to the minimum level of emotional distress, while engaging them in a deep learning experience of a disorienting dilemma. | 212 | Simulation, auditory hallucinations, undergraduate nursing education, qualitative research | Auditory hallucinations | The setup: 2 chairs facing each other in front of the class. 3 volunteer students stand behind the student chair repeating “Don’t listen to her, listen to me” or “It’s ok I like you, I am your friend” or “Just get up and walk out,” representing three auditory hallucinations. Student is instructed to look at the three people standing behind the chair, then to turn back to the instructor. The instructor then asks the participant questions waiting for the answers. If the volunteer cannot answer, or appears in distress, the simulation stops. The instructor stop the voices after 6 sec. | 6 sec | Immediate? | Increased critical reflection, empathy, and academic discourse. | 1-page, self-reflection on the experience | 98% reported increased empathy for the schizophrenic patient hearing auditory hallucinations. 100% reflected gaining an increase in knowledge about, and interest in, auditory and visual hallucinations. 100% identified an increased insight into the experience of the patient experiencing psychosis. A deeper understanding of the stress and anxiety related to auditory hallucinations by the schizophrenic patient and increased professional determination to utilize therapeutic engagement was expressed by 88% of the self-reflections with 92% identifying the short experience as an important clinical experience. | "Self-reflections indicated that the experience of the 6-second hearing voices simulation increased efficacy, insight, knowledge, and intention to use therapeutic communication. The 6-second simulation experience provides educators with a different kind of simulation experience that is easily implemented, nonaggressive, safe for the students, cost-effective, and delivers changes in attitudes and beliefs that can lead to sustained behavior change. In affording the student the opportunity to have a 6-second lived experience of auditory hallucinations, we succeed as educators in facilitating the acquisition of knowing oneself in a brief, controlled, altered condition. According to Hanna and Finns (2008, p. 267), “The only way it is possible to know another human being as a human being, though, is first to really and profoundly know oneself as a human being,” which is the best foundation to engaging in a respectful, honest patient–provider therapeutic alliance." | Marshall B, Bliss J, Evans B, et al. Fostering Transformation by Hearing Voices: Evaluating a 6-Second, Low-Fidelity Simulation. J Am Psychiatr Nurses Assoc 2018; 24: 426–432. | ||||||||
51 | 47 | (Maruca et al., 2015) | Mixed-methods study | 2015 | USA | Nursing students | Implement and evaluate an experiential learning simulation created to enhance nursing students’ empathy during patient care encounters. | 69 | Empathy, nursing students, simulation, caring, clinical simulation | Ostomy care | Students were fitted with a provided ostomy bag in the simulation lab and instructed on how to measure a correct opening of the wafer and apply it. The instructions were to wear the ostomy bag with fecal moulage for 48h continuously while performing normal daily activities. Students were given the freedom to be creative in the moulage of simulated fecal matter in the form of texture and consistency, but not scent. CRL faculty removed the ostomy bag after 48h; students who applied the appliance on a Friday could remove it themselves the following Sunday. | 48h | Immediate submitting on the next lab session | Promoting an emotional response and awareness of the skill of empathy. | The Multi-Dimensional Emotional Empathy Scale used, reflection paper | 85% felt this simulation experience was beneficial for enhancing empathy in clinical practice, strengthening therapeutic relationships and enhancing their empathy toward patients who experience life-changing events. 2 participants reported a negative response to the simulation. | "The assignment was an effective, objective method that utilized simulation to teach empathy to baccalaureate nursing students. Nursing is both an art and science. With today’s tremendous advances in technology and science, incorporating empathy training into nursing education is important and should be considered part of the entire clinical curriculum. The use of a simulation experience that allows students to experience an illness through the patient’s eyes is only one educational activity that can be used to achieve this goal. There are other strategies that nurse educators can use, such as incorporating simulation in the classroom, role-modeling therapeutic communication, or incorporating an evolving case study throughout the semester, with students assigned to the role of the nurse. Interprofessional activities that bring together students from various health care professions to enact a clinical case study can also be used. Using content analysis of student papers was one way to examine and quantify a subjective experience. Despite the limitations of this study, the results do show support for this type of teaching strategy to enhance empathy, at least in the baccalaureate nursing student population. The investigators' previous research on this phenomenon used the qualitative Colaizzi phenomenological method to first understand the student’s lived experience as an ostomate patient. This study expands on that research by using content analysis to determine if the simulated experience was beneficial in increasing empathy evidenced by a higher count of empathic comments. Future studies could expand the implementation and evaluation of this type of simulation in graduate programs and advanced nursing practice programs. By incorporating this type of simulation across all nursing program, from undergraduate to graduate, students will continue to demonstrate empathy in their nursing practice, ultimately elevating the art of nursing." | Maruca AT, Díaz DA, Kuhnly JE, et al. Enhancing empathy in undergraduate nursing students: An experiential ostomate simulation. Nurs Educ Perspect 2015; 36: 367–371. | ||||||||
52 | 48 | (McLaughlin et al., 2020) | Qualitative study | 2020 | UK (NI) | Medical students | Provide a deep understanding of medical students’ experiences of being placed in the role of a hearing-impaired patient by means of a virtual reality (VR) simulation. | 10 | - | Auditory impairment | 360° VR video-learning experience portrayed a consultation with a doctor from a hearing-impaired individual’s perspective.general practitioner was consulting with a patient who presented with a cough. The patient had a viral upper respiratory tract infection. From the patient’s perspective, they were keen to receive an oral antibiotic; however, from the GP’s perspective, an oral antibiotic was not clinically indicated. Therefore, effective communication and dialogue were required to develop a shared understanding of the diagnosis and manage- ment plan between patient and GP.Typical symptoms of sensorineural hearing loss were simulated with processing in the audio frequency domain (eg, attenuation of high-frequency sounds) and in the dynamic domain (eg, attenuation of quieter sounds). Tinnitus, a condition commonly accompanying hearing impairment, was simulated with the addition of two synthesised sounds: a ringing high-frequency pure tone and a hissing white noise with high frequencies attenuated. An Oculus Go VR headset was used for the purposes of this study. Given that the auditory experience was crucial in this VR activity, headphones with enhanced sound isolation were used. | ? | Immediate | Promoted empathetic and critical reflective skills, wider sense of the impact that hearing impairment could have on a patient. Generated a more holistic understanding of what it is to be a patient, living with hearing impairment, to consult with a HCP. Brought to surface attention things that might be considered trivial in communication with patients and could mean a lot to such individuals. | One-to-one interview | Perceived the experience as an emergent whole. Expressed a greater holistic sense of what it is to be a person with hearing impairment, a sense of the challenges involved in communicating effectively. Wanted to have a shared understanding of a consultation with a GP. Gained insights into measures that enabled more effective communication, barriers to it. Experienced how good communication could instil trust and empowerment, and equally, have a more holistic impact on patients and their well-being, how poor communication could evoke a sense of mistrust and isolation. Experienced a greater and voiced an appreciation of how effective communication can have a more holistic impact on patients and their well-being. | "Effective communication skills are important to the success of patient–doctor relationships. This is particularly important for patients who live with hearing impairments. In best preparing medical students to communicate effectively with such individuals, it is important that we focus on more than just the technical aspects of verbal skills. They need to focus on the non-verbal skills and modify their behaviours in order to optimise effective communication. In a person-centred and holistic fashion, VR simulation has the potential to provide a novel complementary training method for medical students. By providing an immersive and memorable learning experience, VR can offer an empathic stepping into the ears of those that live with hearing impairment." | McLaughlin N, Rogers J, D’Arcy J, et al. ‘Sorry doctor….I didn’t hear that….’: phenomenological analysis of medical students’ experiences of simulated hearing impairment through virtual reality. BMJ Simul Technol Enhanc Learn 2020; 0: 1–9. | ||||||||
53 | 49 | (Meyer et al., 2020) | Qualitative study | 2020 | USA | Healthcare students, teaching faculty from nursing, occupational therapy, and speech language pathology disciplines | Examine how a simulation training program may prepare healthcare trainees to treat individuals living with dementia. | 8 | Simulation, transformational learning, dementia, healthcare students, empathy | Dementia | The Virtual Dementia Tour simulation experience involved “garbing” participants in items to replicate the sensory experiences of those living with a cognitive impairment and other comorbidities often experienced by individuals living with dementia (e.g., shoe inserts to replicate neuropathy found in individuals living with diabetes, a risk factor for ADRD). Participants were then given a set of simple tasks to complete in a designated simulation space for a timed period. | 1h | interviews - within 6-moths; reflection papers within 1 week | Elicited a mix of cognitive, physical, and emotional experiences which contributed to a stronger sense of empathy for those living with dementia. Articulated specific actions to take in the future practices. Described wanting to educate other clinicians and family members on the affective experience of what it may be like to live with dementia, in order to help them to understand why certain care practices are required (e.g., patience). Helped to realize why individuals living with dementia and related comorbidities may exhibit certain behaviors. | In-depth semi-structured one- on-one interviews, reflection papers | Enhanced student learning by showing students what it is like to live with dementia and common co-morbidities (“Aha!” moment). Greater empathy for people living with dementia, more developed sense of empathy elicited an emotional response, gave way to ideas about how to apply new knowledge about the experience of living with dementia to improve the lives of individuals living with this condition and common co-morbidities. Showed how much more time it takes to do everyday tasks when living with conditions that alter one’s senses, as well as more time needed to process information such as verbal instructions. Described difficulty remembering the instructions for tasks they were asked to complete during the simulation. Gave the language needed to explain to family members what people living with dementia experience so they could better adapt their behaviors. Learned to contribute to a culture of care – one where the dignity of individuals living with dementia is respected at a societal level. | "Simulation learning provides healthcare trainees an opportunity to experience what it may be like to live with dementia and comorbidities. It provides a valuable transformative experience that allows students to put into practice lessons learned so they may provide optimal care. Students’ deepened sense of empathy appears to inspire intentions to deliver person-centered healthcare, and may equip trainees to better manage behavioral and psychological symptoms of dementia. As such, simulation may be an important and under-used tool to prepare future healthcare providers to serve a growing number of persons living with dementia." | Meyer K, James D, Amezaga B, et al. Simulation learning to train healthcare students in person-centered dementia care. Gerontol Geriatr Educ 2020; 0: 1–16. | ||||||||
54 | 50 | (McGuire et al., 2016) | Mixed-methods study | 2016 | USA | Third-year pharmacy students | Evaluate and measure the impact of traditional large classroom lecture on pharmacy student empathy compared to a smaller elective course which utilized contact-based education, media, and an auditory hallucination simulator. | 14 | Students, pharmacy, empathy, psychiatry | Auditory hallucinations | While listening to the hallucinations, the students completed multiple activities including a word find, number find, job application, and a modified mental status examination which was conducted by one of the course faculty. The students utilized personal headphones and adjusted the volume to a comfortable level. | - | Immediate | Increased empathy scores. Positively impacted pharmacy student attitudes, social distance, and stigma regarding patients with mental illness. | The Jefferson Scale of Empathy Health Professions Student Version (JSE-HPS) with demography | Mean empathy scores increased to 120.00 post-elective. | "The teaching methods employed in the psychiatry elective course, including media, contact-based education and an auditory hallucination simulator, lead to an increase in pharmacy student empathy toward patients with mental illness. Pharmacy educators should continue to explore novel ways to increase pharmacy student empathy toward patients with mental illness. In conclusion, the teaching methods employed in the psychiatry elective course which included media, contact-based education, and an auditory hallucination simulator lead to an increase in pharmacy student empathy toward patients with mental illness." | McGuire JM, Bynum LA, Wright E. The effect of an elective psychiatry course on pharmacy student empathy. Curr Pharm Teach Learn 2016; 8: 565–571. | ||||||||
55 | 51 | (Nario-Redmond et al., 2017) | Mixed-methods study | 2017 | USA | Undergraduate psychology students | Investigate the impact of disability simulations on mood, self-ascribed disability stereotypes, attitudes about interacting with disabled individuals, and behavioral intentions for improving campus accessibility, address this gap with two experiments examining the cognitive, emotional, and behavioral consequences of simulating both single and multiple disabilities in college student samples. | 60 + 50 | Ableism, disability awareness, disability simulation, perspective taking | Disabilites (dyslexia, hearing or mobility impairments, low vision) | In experiment 1 participants were assigned to stations simulating either dyslexia, hearing or mobility impairments. In experiment 2 participants completed low vision, hearing impairment, and dyslexia simulations. Hearing impairment was simulated by wearing ear plugs while attempting to read the lips for a 1-min passage. To simulate dyslexia, students were asked to read a 1-min news story that had each word typed backward. Mobility impairment was simulated by using a hospital wheelchair to get meals. | - | Immediate | Increased negative emotions and self-ascribed disability stereotypes while heightening feelings of empathetic concern (warmth) toward disabled people as a group. Some felt more confused, anxious, embarrassed, helpless, and more vulnerable to becoming disabled themselves, also expressed more pity, interaction discomfort, and felt less competent after the simulations than before. Generosity in the form of volunteer time was not increased. Presented evidence for emotional distress, the taking on of disability stereotypes, increased interaction discomfort, and little interest in helping to improve access on campus. | The 30-item Profile of Mood States—Short Form (POMS-SF), the Interaction with Disabled People Scale (IDPS), and a measure of self-ascribed stereotypic traits associated with disability | Felt more confused, embarrassed, helpless, and more vulnerable to becoming disabled themselves. Empathetic concern (warmth) toward disabled people, but attitudes about interacting did not improve. In Experiment 1, post-simulation anxiety, embarrassment, and helplessness were highest for those who used wheelchairs or simulated dyslexia. Felt more confusion, anxiety, embarrassed, more vulnerable about the disability post-simulation. Were less fatigued—particularly when simulating hearing loss, trying to decipher an oral communication while wearing ear plugs. Combination of disability simulations actually worsened attitudes about interacting with disabled people in the future. Expressed more pity and discomfort about meeting someone with a disability and felt more vulnerable about becoming disabled themselves. Although empathetic concern (warmth) toward disabled people increased, willingness to volunteer to increase campus access did not. Confusion and frustration, embarrassment, and helplessness were experienced. Increased negative moods producing more confusion, depression, anger, and a less active orientation. People feeling more stereotypically disabled themselves: more helpless, less competent, and more embarrassed and guilty. In fact, guilt, frustration and anxiety increased most among those who interacted with disabled people the least | "Simulating disabilities promotes distress and fails to improve attitudes toward disabled people, undermining efforts to improve integration even while participants report more empathetic concern and “understanding of what the disability experience is like.” Educators and rehabilitation professionals have a responsibility to provide students and clients with contemporary, accurate representations of disability informed by best practices such as exposure to first-hand accounts of varied disability experiences. Let us stop perpetuating dated, artificial, and degrading simulations that diminish those living with disability. Practitioners would not consider appropriating the identities of religious, ethnic, or sexual minority groups even if motivated to better understand their circumstances. Since the 1990s, researchers have repeatedly called for the cessation of traditional disability simulations based on scant evidence for their effectiveness. In 2007, an analysis evaluating simulation studies conducted between 1969 and 1996 recommended discontinuation of the “questionable practice,” noting that “disability simulation is an ineffective practice among adults”. Seven years later, a review of disability awareness interventions for children and youth from 1980 to 2011 also concluded that the evidence failed to support the effectiveness of disability simulations. Our studies reaffirm these recommendations with evidence establishing the detrimental impacts of disability simulation for emotional well-being, self-stereotypes, and interaction attitudes. It is our hope that this call for reform is in progress, and that future interventions aim toward increasing the participation and equality of people who experience disability." | Nario-Redmond MR, Gospodinov D, Cobb A. Crip for a day: The unintended negative consequences of disability simulations. Rehabil Psychol 2017; 62: 324–333. | ||||||||
56 | 52 | (Nelson et al., 2018) | Qualitative descriptive study | 2018 | USA | Emergency Medicine interns | Analyze a patient experience simulation for emergency medicine interns as a way to teach empathy and conscientious patient care, explore residents’ perceptions of the simulation, with particular attention to the development of empathy. | 10 | - | Patienthood | Half the interns were patients brought into the emergency department by ambulance as "patients", injured in a motor vehicle accident, and half were family members. Interns then took part in focus groups that discussed the experience. These patients were brought into the ED by a professional ambulance service on a backboard with a cervical collar (C-collar) and were evaluated in the trauma bays by a senior EM resident, a medical student and two nurses. The other half of the interns had the role of “family member” and went through the process of arriving at the ED and locating their family member after an accident. The complete simulation included a full trauma assessment (including the use of moulage clothing that could be cut off), continuing ED care, time in the family waiting room, transport to radiology, splint placement, the need for pain medications, the need to use the bathroom, the use of crutches and receiving discharge instructions. While efforts were made to make the experience realistic, participants were not irradiated with radiographs, did not have intravenous (IV) lines placed and received no medications. | 3h | Immediate | Experienced firsthand many of the challenges of being patients and family members in the ED aspects of care including the discomfort of wearing a cervical collar, the emotional stress of waiting for care updates, and the disorientation of the ED setting. The simulation taught and reinforced several important aspects of being a conscientious and caring provider. Described good communication both in terms of content – setting expectations on the process, setting expectations on the timing and providing updates, and in terms of delivery – making eye contact, having positive interactions. Discussed good patient care in terms of being a patient advocate, being responsive to needs and concerns, and being cognizant of timelines and waits. | Focus group, evaluation form | Experienced firsthand the physical discomfort, emotional stress and confusion patients and families endure during the ED care process. Reflected on lessons learned. Process felt unfamiliar and confusing and they speculated about how patients and families with little medical literacy would feel. The physical discomfort was a surprise to several participants. Felt vulnerable and anxious. Realised the importance of good communication content including setting expectations on the process and timing, and the importance of overall good patient care, which included patient advocacy and being responsive to patients’ needs and concerns pertaining to honoring the relationship and trust between caretaker and patient and family members. Discussed the importance of being responsive to the needs and concerns of patients and families as representing good patient care, being a patient's advocate. | "Conducting a patient experience simulation may be a practical and effective way to develop empathy in EM resident physicians. Additional research evaluating the effect of participation in the simulation over a longer time period and assessing the effects on residents’ actual clinical care is warranted. Empathy, good patient communication, professionalism and humanism are important skills in medicine that not only aid in cultivating the doctor-patient relationship but also improve patient outcomes and physician work satisfaction. Unfortunately, the natural empathy that providers have when they start medical school may wane with the rigors of medical training. To combat this, residency programs must find innovative ways to teach, reinforce and evaluate provider empathy and communication skills. Findings from this study suggest that conducting a patient experience simulation may be a practical and effective way to nurture the development of empathy in EM residents. Additional research is warranted to evaluate the effect of participation in such experiences over a longer time period and to assess the effects on residents’ actual interactions with patients and families while delivering care." | Nelson SW, Germann CA, MacVane CZ, et al. Intern as patient: A patient experience simulation to cultivate empathy in emergency medicine residents. West J Emerg Med 2018; 19: 41–48. | ||||||||
57 | 53 | (Parker et al., 2019) | Qualitative study | 2019 | USA | Pharmacy students | Assess the impact of a diabetes simulation activity on empathy in pharmacy students, increase comfort level with various daily tasks that patients with diabetes are often asked to perform, as well as to assist students in developing a sense of empathy. | 50 | Empathy, pharmacy, student, simulation, diabetes | Diabetes | The simulation activity consisted of having students simulate being a diabetic patient for 3 days. Students maintained daily logs of their actual blood glucose readings (tested twice a day), pre-meal simulated blood glucose readings (students were asked to perform self-blood glucose monitoring twice daily), pre-meal simulated blood glucose readings (generated randomly online and accessed by the student immediately prior to eating), projected required insulin doses for each simulated blood glucose as well as for all carbohydrates consumed throughout the day as meals and snacks (calculated by the student based on an insulin: carbohydrate ratio and an insulin sensitivity factor provided at the beginning of the simulation). Students were required to take a placebo oral medication twice daily and to respond (and document their approach) to a simulated hypo/hyperglycemic event. Black jelly beans were used, as they were deemed as something most students would not be enthusiastic about taking twice daily. Students were asked to inject normal saline as a mock insulin dose once during the simulation. | 3-day | Immediate after the simulation | Positively affected student empathy toward patients with diabetes. Increased confidence in managing select aspects of diabetes management. Perceptions regarding type 2 diabetes changed significantly while perceptions regarding type 1 diabetes did not. | Diabetes Simulation Survey Questionnaire | Increased empathy. | "This 3-day diabetes simulation increased student empathy and confidence in managing select aspects of diabetes." | Parker D, Fontem A, Ojong E, et al. Impact of diabetes simulation on empathy in pharmacy students. Am J Pharm Educ 2019; 83: 69–72. | ||||||||
58 | 54 | (Reed, 2012) | Descriptive study | 2012 | USA | Nursing students | Provide undergraduate nursing students with a simulated laboratory experience, assist nursing students in moving beyond the typical psychomotor skills learned in a laboratory setting to developing personal insight and appreciation for the psychosocial impact an ostomy has on the sexual health and quality of life of individuals. | 134 (>100) | Blogs, ostomy, simulation, undergraduate nursing, education | Ostomy care | Each student, in the role of the nurse, the “patient,” the steps in applying an ostomy wafer and attaching a bag. The experience was made more real as each ostomy bag contained approximately 90 ml of simulated fecal material created by using chocolate pudding, oatmeal, and a small amount of fake fecal odor. While the fecal odor was not strong enough to permeate the clothes, it was noticeable when one's nose was in close proximity of the ostomy bag. | 16-20h | Throughout | The impact of the simulated experience is evident in the depth of awareness and emotion expressed in the blogs. The students collectively acknowledged the value of the activity and the impact the gained awareness had on their careers as nurses. | Blog (no assessment) | Discomfiture was felt taking public transportation or riding a bike home while wearing white scrubs and the ostomy appliance. Several students faced strong negative reactions from non-nursing major roommates. Opportunity for the couple to engage in frank dialogue the challenges a relationship faces when one of the partners experiences a chronic illness or permanent injury and whether or not their relationship was strong enough for such challenges. Shared an uncomfortable “awareness” of the ostomy bag throughout the night and experienced worry that it would break open. Cases of skin tenderness occured when students removed the ostomy wafer. | "The use of social technology and the provision of learning activities, not available on the clinical unit, can have a significant impact on the cognitive, psychomotor, and affective development of nursing students. This learning activity was designed to assist nursing students in developing the collective skill set, cognitive, psychomotor, and affective, required to reduce an ostomate's sense of social isolation and promote therapeutic nurse/ patient discussions. It provided nursing students with a learning opportunity not possible in a clinical setting. The utilization of social technology students were familiar with and the use of simulation in a safe, nonthreatening manner, fostered student insight and elevated confidence transferable to the clinical environment in a manner which will affect positive patient outcomes throughout the students’ nursing careers." | Reed KS. Bags and blogs: Creating an ostomy experience for nursing students. Rehabil Nurs 2012; 37: 62–65. | ||||||||
59 | 55 | (Riches et al., 2019) | Mixed-methods cross-sectional study | 2019 | UK | Trainee & qualified clinical psychologists | Pilot and evaluate a newly designed simulation of auditory hallucinations as a future training tool for clinicians. | 25 | Clinical psychology, mental health, psychosis, training, voice hearing | Auditory hallucinations | Participants attended the London‐based immersive art exhibition, Altered States of Consciousness (ASoC), which included an auditory hallucinations simulation. The exhibition aimed to improve understanding of what it feels like to hear voices by providing with an individualized simulation of auditory hallucinations. Participants were guided through a gallery. A pre‐recorded audio guide described the artworks. Audio was repeatedly overlaid by “voices” performed live by professional actors. The actors performed voice “characterizations” developed in work- shops with young people who hear voices and aimed to reflect the range of auditory hallucinations, from positive to negative, through live enactment to participants via the audio guide headphones. Participants were assigned a unique audio guide, and their physical description was covertly noted at the initial greeting and conveyed to actors. | - | Immediate & 6-months after | Affected subjective understanding, compassion, and comfort. Experienced comparable phenomenological experiences, with identifiable cognitive, emotional, and behavioural dimensions, to people with lived experience of voice hearing. Provided numerous benefits to training and clinical practice, including increases in subjective understanding, compassion, and confidence. Emphasized the importance of and desire for experiential learning in relation to auditory hallucinations and other psychotic experiences. | Pre‐simulation and post‐simulation 100‐point visual ana- logue scales & self‐reported demographic characteristics & semi-structured interview | Increased in subjective understanding, compassion, and confidence, and suggested several future training applications for the simulation, including with a range of health care professionals. Significant increases in understanding what it feels like to hear voices (large effect), compassion towards people who hear voices (large effect), and comfort talking to people who hear voices (medium effect). Current happiness decreased (large effect), and change in stress was not significant. | "Therefore, we conclude that this simulation has potential for training clinical psychologists and other health care professionals who work with people who experience auditory hallucinations. Trainee and qualified clinical psychologists took part in a new immersive art exhibition, which aimed to provide an individualized voice‐hearing simulation experience in a real‐world setting. Results indicated that the simulation provided significant increases in their subjective understanding, compassion, and comfort in relation to auditory hallucinations and had given them more confidence in their clinical work. There was broad consensus among participants that the simulation could have positive future applications for clinical training." | Riches S, Khan F, Kwieder S, et al. Impact of an auditory hallucinations simulation on trainee and newly qualified clinical psychologists: A mixed-methods cross-sectional study. Clin Psychol Psychother 2019; 26: 277–290. | ||||||||
60 | 56 | (Robinson & Rosher, 2014) | Mixed-methods study | 2014 | USA | Third-year medical students | Allow students to experience the functional decline that may occur with normal aging, while learning how function can be improved by simple environmental adaptations, also to sensitize the student to the aging changes. | 49 | Medical students, geriatrics, ageism, attitudes, simulation experience | Old Age | During simulation experiences, students wore glasses with yellow lenses (normal yellowing of the lenses), cotton balls in the ears (presbycussis), rubber gloves with the index finger taped to the third finger (decreased tactile sensation & fine motor dexterity), and an immobilizer on one extremity (mobility problems). Parti cipants also experienced the difficulty in performing various common tasks; however, different from other programs, they also experience how the activity is made easier, function enhanced, and quality of life improved by simple environmental adaptations. For example, students are asked to lace a white shoe with a white shoelace. Then they are asked to lace a dark shoe with a white lace. They are able to see how much easier the activity becomes when contrasting colors are utilized. | 3h | Immediate | Improved student attitudes in the instrumental-ineffective domain. | Sub-scale of the Aging Seman- tic Differential Scale, discussion, evaluation of the class. | Improvement in attitudes toward aging as a result of the class. attitudes did improve on the autonomy, integrity, and acceptability subscales, the scores were not statistically significant. | "The demographic shifts are nearly upon us, and we must do more to prepare future physicians to provide competent, effective, compassionate, and sensitive care for the elderly. Simulation experiences and other types of educational endeavors taught with an interdisciplinary approach that focus on measures that can maintain and improve functioning should help students see the challenge and the possibilities for improvement in quality of life of elders." | Robinson SB., Rosher RB. Effect of the ‘Half-Full Aging Simulation Experience’ on Medical Students’ Attitudes. Gerontol Geriatr Educ 2001; 21: 3–12. | ||||||||
61 | 57 | (Saiva et al., 2020) | Mixed-methods study | 2020 | Canada | Psychiatry residents | Explore the effectiveness of an immersive simulation experience using an aging simulation suit for fostering empathy towards geriatric patients with advanced mental illness. | 15 | Simulation, empathy, aging suit, geriatrics | Old age + auditory hallucinations | Wore an aging simulation suit to perform the task of meeting with a pharmacist to review current medications and prepare a dosette. Concurrently, with the physical restrictions imposed by the suit (goggles (vision loss), earplugs (age-related hearing loss), gloves (reduce sensation in the hands and impair fine motor tasks), and weights and braces (restrict mobility and simulate joint stiffness)) an audio file was played through headphones to simulate auditory hallucinations. Recordings were largely negative in content, at times inaudible, and sporadic. | 10-15 min | 3 month | Increased empathy towards the aging population. Presented understanding the experience of the patient but also communicated the understanding and intentionally changed practice. Shared an overwhelming sense of awareness and practical understanding of the patient’s perspective beyond just an intellectual understanding. | The Health Professional (HP) version of the Jefferson Scale of Empathy (JSE), reflective writing exercise, debrief transcription, and evalu- ation questionnaire. | Improved understanding and awareness of the patient perspective and the ability to communicate this understanding and show intentions to help through practice change. 14 participants indicated “increased” (n = 8) or “strongly increased” (n = 6) empathy for geriatric patients following the immersive experience. Found the voices simulating auditory hallucinations to be challenging. Recognized feelings of distress, anxiety, and frustration and found the process to be mentally exhausting and distracting. Feelings of self-consciousness and vulnerability were evident. Intentions of being more patient and slowing down the interaction by adjusting the pace at which elderly walk and speak, explicitly ask patients questions about their physical limitations (hearing or sight) to better understand its impact on their medication management and any need for accommodations. | "An aging suit simulation with debriefing may be an effective educational intervention to incorporate into the medical curriculum to foster empathy for this stigmatized population. This study supports previous studies in demonstrating that immersive, first-person simulation can be an effective component within medical training to foster empathy among healthcare profes- sionals for our aging population." | Saiva A, Abdool PS, Naismith LM, et al. An Immersive Simulation to Build Empathy for Geriatric Patients with Co-Occurring Physical and Mental Illness. Acad Psychiatry 2020; 44: 745–750. | ||||||||
62 | 58 | (Sideras et al., 2015) | Exploratory pilot study | 2015 | USA | Nursing students | Determine if students who participated in the simulated learning activity would demonstrate (a) greater knowledge about mental health problems, (b) reduced negative attitudes toward individuals with schizophrenia, (c) greater empathy, and (d) greater behavioral intent to interact with clients with mental illness as compared with those who experience traditional mental health didactic and clinical learning experiences. | 145 | Stigma, live-actor simulation, psychiatric nursing, empathy, hearing voices, schizophrenia, nursing students, standardized patients | Schizophrenia | Students listened to audio players via headsets that provided the auditory hallucinations. While listening to the voices, students rotated through four workstations designed to simulate real-world conditions for clients that required student to interact with people while hearing voices. The stations included a mental status examination, a reading comprehension test, performance of a community task, and completing puzzles. | 1h | Immediately | Negative attitudes toward individuals with schizophrenia were reduced. Reported less fear and great behavioral intent to interact with the mentally ill. No significant difference in empathy. | 10-item Fear and Behavioral Intentions (FABI) question- naire, abbreviated nine-item Attribution Questionnaire (AQ-9), discussion, The Level of Familiarity Index is a 12-item assessment, standard demographic information, the Mental Health Knowledge Schedule (MAKS), Jefferson Scale of Empathy (JSE). | Significantly lower negative perceptions with no significant change in empathy. There were no significant differences on the level of empathy as measured by the JSE, less fear and more behavioral intent to interact with individuals with schizophrenia (lower FABI scores). Negative attitudes toward individuals with schizophrenia were reduced | "Providing students opportunities to gain real or simulated experience with clients with schizophrenia may reduce negative perceptions. The intervention showed improvement in negative emotions of student nurses related to individuals with schizophrenia, particularly for participants with less experience at baseline. The moderating effect of level of experience was evident for student report of decreased fear and increased intent to interact. Understanding baseline experience of students with individuals with mental illness may be useful in directing use of simulation. Providing opportunities to gain experience with clients with schizophrenia may help to reduce stigma." | Sideras S, McKenzie G, Noone J, et al. Impact of a simulation on nursing students’ attitudes toward schizophrenia. Clin Simul Nurs 2015; 11: 134–141. | ||||||||
63 | 59 | (Skoy et al., 2016) | Qualitative study | 2016 | USA | Third-year professional pharmacy students | Increase student pharmacist empathy through the use of an auditory hallucination simulation. | 81 | Simulation, mental illness, empathy, pharmaceutical care laboratory | Auditory hallucinations | Prior to the simulation, faculty members provided students with a compact disc players with the simulation disc, nonnoise canceling headphones, and an informed consent document. During the introduction, students were told they would complete a series of seven stations while listening to a recording of simulated auditory hallucinations. To accommodate each student, there was a duplicate of each station, so two students could be participating at the same station simultaneously. Each student was given a checklist to keep track of completed stations. Students were asked to start the recording and adjust the volume to a comfortable level, but not adjust the volume thereafter even if the recording became extremely quiet or loud. The simulation toolkit supplied resources and station suggestions related to activities of daily living such as: reading comprehension, following directions, communicating with others, and cognitive functions, activities related to pharmacy practice such as following a prescription consultation. | 45 min | Immediately | Increased empathy. The need for taking another’s thoughts and feelings into account when deciding treatment and the need for understanding the world from another’s perspective was observed. Reported feeling distressed, anxious, uncomfortable, and/or embarrassed during the simulation. Reported that feeling distracted, having difficulty concentrating, and at times responded aloud to the voices they heard. | The Kiersma-Chen Empathy Scale, reflective essay, debrief | Demonstrated a gain in empathy for all questions. 64% of students reported feeling distracted or having difficulty concentrating during the simulation. 83% reported a gain in empathy or understanding for patients who experience auditory hallucinations. 22% addressed the impact auditory hallucinations have on everyday tasks for patients. Increased ability to communicate and recognize patients who are experiencing auditory hallucinations. 40% of students stated the simulation altered the way they will communicate health care information to patients potentially affected by auditory hallucinations. | "With approximately 10 million adult Americans suffering from serious mental illness, it is important for pharmacy educators to prepare students to provide adequate patient care to this population. This auditory hallucination simulation increased student pharmacist empathy for patients with mental illness. Implementation of the Hearing Distressing Voices auditory simulation taught students what experiencing auditory hallucinations may feel like and how it affects patients’ daily tasks. The simulation also increased student empathy for patients who experience auditory hallucinations. Use of the simulation may increase the efficacy of commu- nication between pharmacy students and patients who experience auditory hallucinations." | Skoy ET, Eukel HN, Frenzel JE, et al. Use of an auditory hallucination simulation to increase student pharmacist empathy for patients with mental illness. Am J Pharm Educ 2016; 80: 1–6. | ||||||||
64 | 60 | (Slater et al., 2019) | Qualitative exploratory study | 2019 | UK (NI) | Front‐line staff, carers and befrienders, senior management including service managers and directors of Nursing, allied health professionals (AHPs), medical/psychiatry staff, other (i.e. educationalists and dementia service managers) | Explore the impact of the immersive Virtual Dementia Tour on moral, emotive, behavioural and cognitive elements of empathy. | 18 | Caregivers, empathy, healthcare professionals, hospital, Virtual Dementia Tour | Dementia | VDT® programme mimiced the symptoms of level 4, moderate dementia. Participants were not briefed about the VDT® process prior to entry. The VDT® process manipulates both physical and cognitive elements in a standardised format and timeframe. It starts by creating the physical symptoms of age, with yellow‐tinted goggles (eye disease), insoles with corn kernels inbuilt creating painful sensations (peripheral nerve damage), gloves are designed to make it difficult to use your hands (arthritis). The cognitive effects of dementia were re‐created by noise via headphones (chaotic mental state, similar to what some people with dementia experience). During the VDT, the subject performs simple tasks such as pair socks. The session concludes with an opportunity to observe others (to consider the verbal and non‐verbal reactions to the experience) and then attend a debriefing exercise | - | - | Emergence of an empathic response. Increased understanding of the imagined experience of dementia and facilitated an emotive, moral and cognitive impression of empathy. Elicited emotional responses of fear, frustration and helplessness. Felt that prior education did not prepare them to care for some with dementia or the array of symptoms associated with this condition. Reported the subjective sharing of feelings with a person with dementia and provided evidence of the complexity and cycle of this response driven by identification. Helped many to reflect upon the care they delivered to a person with dementia, recognising missed opportunities and lack of understanding of dementia. Informed a moral and empathic reflection, leading to changes in practice, such as recognising the power of touch to connect to people with dementia, the volume and tone of language, together with the maintenance of eye contact. | Interview | Feelings of anxiety, fear and acute feelings of vulnerability, disorientation, isolation and powerlessness were widely reported. As the training progressed, anxiety shifted towards feelings of frustration, stress and annoyance which was attributed to not being able to master simple tasks and/or lack of ability to rely on their everyday senses. Ability to complete a small task created a sense of satisfaction and an achievement for some. Experienced realisation of the need to revise participants practice to ensure they adopted a person‐centred approach ensuring focus on the person not the condition. Reflected on the care delivered in the past and feel shame and guilt for the way they previously cared for a person with dementia. Helped to grasp why some people with dementia adopt behavioural and psychological responses such as wandering, feeling aggression and agitation. Felt more confident to care, be more empathetic and viewing patients care holistically, and leading to a self‐reported change in behaviour, by providing more time, maintaining eye contact, listening and providing reassurance were cited. More awareness and a greater appreciation of the effect of the environment upon the person with dementia. Recognition and attendance to the “little things” that matter. | "In this study, the VDT® experience appears to be a learning tool, which immerses the participant into experiencing the imagined reality of having dementia and emotional consequence of that experience. Empathy was viewed as a multi‐dimensional phenomenon, with emotional, moral, cognitive and behavioural (communication) components. Participants reported the emergence of an empathic response. This study provides an insight into the different components but calls for further research in this area. There are several arguments in favour of virtual simulation in health care such as enabling participants to learn in a simulated risk‐free environment and perform. However, virtual simulation training reflects an imaged experience of what it is like to live with dementia and the lack of evidence exists that it results in demonstrable behaviour change. In conclusion, virtual reality programmes provide additional opportunities to enhance skills and ability to offer a practical person‐centred approach to developing an awareness of dementia from the viewpoint of the person." | Slater P, Hasson F, Gillen P, et al. Virtual simulation training:Imaged experience of dementia. Int J Older People Nurs 2019; 14: 1–12. | ||||||||
65 | 61 | (Smith et al., 2018) | Mixed-methods longitudinal study | 2018 | UK | Nurses | Evaluate the impact of a brief educational intervention on sensory impairment, in the form of training workshops with community nurses on their knowledge, attitudes and practice pre- and post-intervention. | 41 | Community nursing, remote and island, Scotland, sensory impairment, sight and hearing loss, simulation. | Sensory impairment | Simulation scenarios gave participants the opportunity to experience examples of sight and hearing impairments and their impact on aspects of daily living. For example, wearing sight impairment simulation spectacles, participants attempted to perform simple everyday tasks such as filling out forms, opening and closing clothing buttons and managing medication. | 3-4h | Immediate , 3-months & 6-months after | Improved participants’ knowledge of both sensory impairments and associated disability, positively impacting on participants’ practice. Increased awareness of the potential for sensory impairment in their patients. Described greater understanding and empathy with patients who experience sensory impairment, a more robust approach to patient assessment to identify impairment, and increased likelihood to inform of, and refer to, sensory services. Presented change in approach to patient assessments, with greater evidence been increasingly considered the potential for sight and hearing impairments, were more likely to discuss sensory impairments with patients and document the assessment. Participants suggested that some patients may had become resigned to their condition and were therefore reluctant to seek advice about their impairment. | Pre- and post-workshop questionnaire, postal questionnaire, focus group interview | Increased awareness of the potential for patients to have a sensory impairment, greater understanding and empathy with patients who experience sensory impairment, more robust patient assessment to identify impairment, and increased likelihood to inform of, and refer to, sensory services. Improved knowledge of sensory impairments. Most significant was the impact of social isolation. | "Community nurses are often well placed to identity disabilities and patients at risk of injury because of sensory impairment. Participation in simulation training can help to develop greater awareness of the impact of that sensory impairment. Knowledge of specialist services will increase the opportunities for referral to services and impact positively on the lives of older people living in rural settings. Provision of accessible education on sensory impairment for health and social care professionals can enhance care delivery to older people. The results of this study begin to address the gap in sensory education for healthcare professionals in general and community nurses in particular. Accessible training programs for healthcare workers that focus on sensory impairment challenges including simulation and relevant interventions can help support improved patient outcomes. This study was carried out in an area where accessible service provision, including referral pathways for people with sensory impairment, is well established, which perhaps influenced workshop participants’ perceptions and confidence. The sample was drawn from a single rural island Health Board within Scotland and included mainly community nurses rather than other healthcare providers. The views of other health and social care professionals are equally valid and may help to identify further education needs and services gaps that can help to inform a multidisciplinary approach to address the needs of older people with sensory impairment in the community. The study helps to demonstrate the importance of raising awareness of sensory impairment with healthcare workers and community nurses. From a preventative standpoint, there is good evidence that correcting hearing and sight impairments can lead to improvement in the quality of life and functional status of older people and this evidence in itself supports the importance of awareness raising and education about sensory impairment. Even mild impairments exert a toll on older adults, yet most sensory problems are potentially treatable or relieved by interventions and environment adjustments. Community nurses are often well placed to identify sensory impairment, associated disabilities and patients at risk of injury, and nurses usually have high public visibility in small communities. Accessible and relevant education about sensory impairment for all health and social care professionals who deliver direct care to older people across all care settings is therefore highly relevant to facilitate both recognition of that impairment and access to appropriate interventions. With the population of older people ever expanding, the impact of sensory impairment is likely to become an increasingly significant health and social care burden without due attention to appropriate training of health and social care professionals." | Smith A, Shepherd A, Macaden L, et al. Raising awareness of sensory impairment among community nurses: a brief intervention in a remote island setting. Rural Remote Health 2018; 18: 1–15. | ||||||||
66 | 62 | (Solberg et al., 2020) | Qualitative study | 2020 | USA | Nurses & post-care assistants | Increase their sensitivity and knowledge about delirium and to develop a “delirium nurse champion” for each hospital unit. | 389 | Delirium, nursing education, dementia, non-pharmacologic interventions | Dementia | The VDT is a simulation learning program in which cognitive impairment and other aging syndromes are experienced firsthand to increase provider sensitivity and awareness about aging syndromes, including sensory losses and cognitive decline. | - | Immediate and after 4-month | Showed significant changes in attitudes about caring for patients with delirium, including increased confidence in recognizing, treating delirium and improved understanding of the implications of dementia. | Pre and post-test of seven questions, 4-month post program survey | Increased understanding of the experience and abilities of people experiencing cognitive impairment . Increased self-confidence and ability to recognize signs and symptoms of delirium, administer a delirium screen, implement nonpharmacological delirium interventions and provide overall better care. | "Nursing Education about delirium that includes instruction on a standardized screening tool, documentation, and non-pharmacologic interventions improved knowledge and recognition of delirium and may have changed attitudes surrounding delirium in the hospital. Improving bedside nurses’ knowledge of delirium, providing access to consultative experts, and designing evidenced based decision-making tools help in changing the culture of delirium care in our hospital. Using education and including nurses in the development and implementation can produce feelings of empowerment and ownership, which when strengthened by evidence-based decision tools that are easy to use and easy to incorporate into busy clinical practice can change the culture of delirium. In developing this approach, we tried to create a circle of sustainability by incorporating the training into new clinical employee training and annual training. The intervention may durably improve knowledge of delirium, and it is plausible that culture surrounding delirium care has changed in the hospital with improved capability to recognize and treat delirium as the medical emergency for which it is identified." | Solberg LM, Campbell CS, Jones K, et al. Training hospital inpatient nursing to know (THINK) delirium: A nursing educational program. Geriatr Nurs (Minneap) 2020; 42: 16–20. | ||||||||
67 | 63 | (Sterrett et al., 2012) | Mixed-methods study | 2012 | USA | Third-year pharmacy students | Determine student competency and confidence in the provision of diabetes care and satisfaction with incorporation of the American Pharmacist Association/American Association of Diabetes Educators (APhA/AADE) diabetes certificate program into the required doctor of pharmacy (PharmD) curriculum. | 79 | Diabetes, diabetes certificate, disease management, assessment, American Pharmacists Association | Diabetes | Students were provided additional hands-on training and then required to demonstrate appropriate performance of insulin injection, diabetic foot examination, blood pressure measurement, and blood glucose monitoring. At each station, laboratory instructors completed the assessments and documentation required by APhA. To further enhance these skills, students were given supplemental laboratory exercises that required them to complete OSLEs. In addition, students were required to participate in a week-long simulation where they had to live the life of a patient with diabetes. | 1 week | - | Student confidence in diabetes knowledge, skills, and attitudes was high after com- pletion of the program. | 8-question survey instrument, annonymous-vopluntary survey | High student confidence in their ability to provide diabetes care (mean scores 4.2 to 4.8) and satisfaction with the program (mean scores 4.5 to 4.8). | "Longitudinal integration of a nationally recognized diabetes certificate program into the required PharmD curriculum produced satisfied students competent in providing diabetes pharmaceutical care. Incorporating the APhA/AADE diabetes certificate program longitudinally into a required pharmacy curriculum allowed for all pharmacy students to be recognized providers in a national certificate program. After completion of the program, students were competent and confident providers of diabetes pharmaceutical care. Students were highly satisfied with the certificate program and it can serve as a model for other pharmacy colleges and schools to help advance the profession." | Sterrett J, Croom M, Phillips CM, et al. Incorporating a diabetes certificate program in a pharmacy curriculum. Am J Pharm Educ 2012; 76: 1–8. | ||||||||
68 | 64 | (Ter Beest et al., 2018) | Qualitative descriptive study | 2018 | Netherlands | Bachelor nursing students | Explore what nursing students learn about empathy in the relation nurse–patient, while they lie in bed as a patient seeing the nurse from another perspective. | 75 | Nursing education, empathy, patient perspective, experiential learning, simulation | Patienthood | In the preparation of the hospital simulation students did small exercises to experience disabilities and discussed what it means to live with disabilities. During the preparation, students randomly received an illness description, prepared themselves by making their own patient record: creating a combination of their daily life, their own social environment and the description of the patient role with the nursing diagnosis of Gordon’s Functional Health Patterns, such as health perception, nutrition and elimination. The students had to bring a bag with insurance papers, night suit, toothbrush and slippers and a book, if desired. First, a faculty member prepared the students with make-up and attributes such as a fake stoma, bandages, braces or cannula. Students layed in bed as patients in a hospital room with 3 other student–patients. At the start of the simulation, the curtains around the bed were closed to give the student time to adjust to the situation. Nursing students of the same year had the role of nurse and students from other healthcare studies intervened in the simulation as physiotherapist, speech therapist or dietitian. Faculty members played the role of doctor. One faculty member was tutor and gave directions to the student– nurses to give the basic care to the patients and organise the work. | ~8h | Immediate | Experienced the need for empathy and were confronted with the patient’s experiential world, being dependent, enduring hospital life and needing attention from the nurse. Understood the significance and difficulties of feeling empathy for patients. | Reflection, an image to illustrate the impact of the patient experience. | Awareness of the particularity of being healthy themselves and trying to imagine what illness would mean in their personal life. Showed awareness of endurance in the short term: waiting and feeling bored and in the long term by enduring a life with limitations, suffering and loss, surprised by how different the patient’s perspective was from the nurse perspective. Demonstrated the importance and difficulties of the relationship with a nurse in the unknown hospital world for the student–patient. Small moments of influence made a big difference. Issue of using the bell or not when they needed help or wanted attention. Asking for help was not easy. Delivering no attention to the student–patient, had immediate effect on the well-being, self-worth and identity of the patient. In the experience of the students, a patient was somebody they did not want to be, something negative. | "The change in perspective in the hospital simulation gives nursing students valuable insights in the importance of empathy in the relation patient–nurse. Four themes were identified: endurance, silent scream for attention, scary dependency and confrontation with the role of patient. Students learned about the possibilities and difficulties of empathy in different stages of the simulation. A hospital simulation with bachelor nursing students in the role of patient is a useful and practical perspective changing learning method, on condition that there is a solid preparation. The four stages of the simulation give important eye-openers and reflections on dependency, endurance, cry for contact and confrontation being a patient. Experiential knowledge about the patient’s perspective and receiving empathy emphasised the importance of a good nurse–patient relationship and gave students points of concern for their practical periods and work as a nurse. Empathy is a complex and layered concept and especially an attitude of interest and attention and skills to step into the shoes of a patient needs practice in nursing education." | ter Beest H, van Bemmel M, Adriaansen M. Nursing student as patient: experiential learning in a hospital simulation to improve empathy of nursing students. Scand J Caring Sci 2018; 32: 1390–1397. | ||||||||
69 | 65 | (Tremayne et al., 2011) | Mixed-methods study | 2011 | UK | Second-year adult-branch nursing students | Enhance the appreciation of some of the physical and sensory difficulties with which older patients might present. | 90 | Empathy, simulation, students | Old age | The suit comprises of goggles simulating decrease in peripheral vision when rods from the peripheral retina are lost, and deteriorating vision as a result of the lens becoming thicker and cloudy leading to cataracts; a back protector gives the wearer a bent posture and restrictors on the elbows and knees make motion sluggish, replicating deterioration in joints, cartilage and collagen caused by ageing. In addition, 500g weights for the wrists and 1kg weights for the ankles recreate loss of arm and leg muscle, and gloves reduce tactile sensitivity which diminishes with age. In this suit hearing loss is stimulated by ear plugs blocking high frequency sounds. The nurses in the role play were asked to make the patient a drink in a kitchen area with a choice of implements. The patient was able to find the plastic up in a holder and struggled to keep a grip on it, often resulting in the nurses taking the lead by helping patients with their drink rather than encouraging independence by using more appropriate equipment. After the exercise consideration was given to the choice of feeding of equipment. During the next scenario nurses helped a patient to go to the toilet, they assisted the patient out of the chair and help him or her with the toilet. When walking, the nurses were often at the patient's site and the air plugs inhabit the patients hearing and disorientated them. | 1h | Immediate | Challenged the nursing students perspectives of how older people are cared for in hospital and reinforced the idea that caring for the older persons requires specific knowledge and skills. Encouraged pier team working increased confidence and awareness of the need to work in a collaborative manner to improve the effectiveness of care delivery. Empathy was evident in the difficulties encountered. Prompted the nursing students to reflect on the significance of relationships with patients and on previous practise highlighting how nurses negatively reinforce a learned helplessness and how the older institutionalised patient is at a greater risk of the state of passive behaviour. | Evaluation-tool with a Likert-style scale (1 to 5) | Treated differently, indicated a frustration with peers for a lack of insight about the difficulties they were experiencing. Found it beneficial to observe how others would address certain problems. | "The age simulation suit is a useful learning aid to demonstrate the muscular skeletal visual and auditory effects of ageing. Role play provided a beneficial context for nursing students to reflect on their clinical practise. With an ageing population it is essential that nurses appreciate what it may feel like to be an older person. In doing so the nurse will have an enhanced understanding of the difficulties an older person may encounter in daily activities, such as standing up from a sitting position. Nurses need to recognise that this stage of life involves many challenges, and that old age is an evolving adaptation to all aspects of being. Nursing practises need to meet the specific requirements of older people and the care delivered to them." | Tremayne P, Burdett J, Utecht C. Simulation suit aids tailored care. Nurs Older People 2011; 23: 19–22. | ||||||||
70 | 66 | (Trujillo et al., 2009) | Mixed-methods study | 2009 | USA | Pharmacy students | Implement and assess the effectiveness of an exercise designed to develop pharmacy students’ empathy toward patients regarding diabetes and obesity and encourage cultural and ‘‘economic’’ competence, give students a better appreciation and understanding of how these factors affect nutrition choices and diabetes prevention or management and be able to use the lessons learned when interacting with patients. | 122 (43) | Cultural competence, empathy, diabetes, nutrition, health improvement, disease prevention | Diabetes | Students monitored their own nutritional intake (online nutrition and exercise journal), and grocery shopped based on an assigned patient scenario. For this activity, students calculated their basal metabolic rate and assessed their own nutritional intake by using the FitDay Web site. The Diabetes Shopping Experience, was build upon the Nutrition Journal assignment and involved students taking a shopping trip to a grocery store. Students were assigned 1 of 5 patient scenarios and went grocery shop as if they were the person in the scenario. The scenario provided important information, such as income, insurance coverage, family size, concurrent disease states, medication lists, and the name and address of the grocery store where the person in the scenario shops. The patient scenarios included people from diverse ethnic backgrounds, ages, socioeconomic levels, and family situations. At least 1 person in the patient scenario had type 2 diabetes. | 5 days (2-4h) | Immediate | Attitudes, empathy and confidence levels regarding health promotion and disease prevention improved. Greater appreciation of the difficulties patients have with healthy eating and improved empathy towards patients with diverse cultural and socioeconomic backgrounds. | Reflective assignments, online survey (1-week prior) | Improved student confidence levels regarding nutrition and weight-related patient counseling, and knowledge about general nutrition and weight management. Improved their ability to empathize with overweight patients regarding the challenges of nutrition and lifestyle changes and enhanced their awareness of the impact that cultural and financial situations have on nutrition and lifestyle. Confidence ratings for all 4 counseling activities related to nutrition, physical activity, or weight loss improved, with the most dramatic improvement seen for diabetes about appropriate nutrition and physical activity The percent of students agreeing that it is challenging for a patient with diabetes to adhere to a healthy diet significantly increased after completing the activities. | "The Nutrition Journal and Diabetes Shopping Experience positively impacted the way pharmacy students view the challenges surrounding nutrition and healthy eating in patients with culturally and socioeconomically diverse backgrounds. The Nutrition Journal and Diabetes Shopping Experience helped to bridge an identified gap in our curriculum and more effectively meet our ability-based educational outcomes. The activities targeted contemporary, attitudinal-based outcomes with which many schools are currently struggling, by promoting active-learning, oral and written communication, and self-reflection. In addition, this experience takes learning outside of the walls of the classroom and into the communities that the students may serve when they become pharmacists. Survey responses and comments indicated that the goals of the activities were met. Finally, the ability to incorporate this experi- ence without requiring additional resources makes it both innovative and meaningful." | Trujillo JM, Hardy Y. A nutrition journal and diabetes shopping experience to improve pharmacy students’ empathy and cultural competence. Am J Pharm Educ 2009; 73: 1–11. | ||||||||
71 | 67 | (Varkey, et al., 2006) | Preintervention and postintervention study | 2006 | USA | First-year medical students | Evaluate the effectiveness of a modified aging game to enhance the attitudes of caring for elderly patients, enhance empathy for elderly patients, and improve general attitudes toward the elderly. | 84 | Geriatric education, simulation, aging game, caring for elderly | Old age | The students are given a small plastic bag containing spending money, an ATM card, shopping list, 3 colored chips representing all of their major financial assets (house, car, etc), and 3 white chips representing their self-esteem. The students were asked to wear a pair of heavy rubber gloves (decreased manual dexterity) and goggles with a film of clear tape over the lens (cataracts). Each pair of students was given a bag containing 7 prescription bottles and asked to take the pills out with different regimens of dosing and frequency. Each student was required to visit the “town,” which includes a grocery store, restaurant, and post office. The students wore the “cataract” goggles to simulate visual impairment, foam earplugs (presbycusis), kernels of un-popped popcorn in one shoe (arthritis), and a pair of heavy athletic stockings on the other foot (pedal oedema), an elastic bandage wrapped tightly around their knees (parkinsonian gait) and were given a walker. In the grocery store each student was given a list of items to “purchase.” The restaurant simulates a dimly lit eating establishment with menus that are extremely difficult to read while wearing the “cataract” goggles. All students were later given patient gowns to wear over their clothes and were placed in wheelchairs. Several students were labelled as incontinent and are placed in diapers with incontinence pads placed on their wheelchairs. The nursing assistants hurriedly feed applesauce and give sips of water. Any attempt by the students to feed independently is met with a negative response from the nursing assistant since they are capable of doing the job so much faster. The students quickly learn to surrender any thoughts of maintaining their functional independence. Generally, in every group there are 1 or 2 students who demonstrate resistance to cares provided by the “bad” nursing assistants or become somewhat agitated. These students are placed in wrist and/or body restraints. A nursing home physician and nurse make rounds among the residents. They talk freely about the resident’s continence status and cognitive losses such that many others are able to hear the discussion. The “good” nursing assistant attempts to have some interaction with all of the students. | 3h | Pre/post (assumed immediate?) | Movement toward a more positive outlook. | 11-question modified Maxwell and Sullivan questionnaire, and the Aging Semantic Differential (ASD). | Statistically significant improvement in 6 of the 8 attitudes toward caring for elderly and increase in empathy towards elderly patients. Stated the aging game added significantly (61.5%) or moderately (37.3%) to knowledge and skills in patient care for the elderly. Difficulties opening childproof medication containers, reading the small print instructions on the bottles, and see the number of pills that must be taken in a given day. Comment on experienced feelings of vulnerability and a sense of suspicion that develops toward other people. | "With the exponentially increasing number of elderly in the United States, it is crucial to train physicians who are well versed in aging-related health issues and are empathetic toward geriatric patients. A simulation experience like the aging game is one method of improving the empathy and attitudes toward caring for the elderly earlier on in the medical school curriculum. Included in the experience should be discussions or experiences of successful aging as well. Longitudinal assessment of the effect of the aging game in maintaining the positive effect on empathy and attitudes toward caring for the elderly and especially in clinical practice needs to be done." | Varkey P, Chutka DS, Lesnick TG. The Aging Game: Improving Medical Students’ Attitudes Toward Caring for the Elderly. J Am Med Dir Assoc 2006; 7: 224–229. | ||||||||
72 | 68 | (Waldo et al., 2013) | Qualitative descriptive study | 2013 | USA | Nursing students | Create a holistic learning environment for students to better grasp caring for the whole person also to illicit the students’ perception and experience of a new Psychiatric Mental Health clinical experience “A Day in the Life". | 19 | Psychiatric/mental health, simulation, nursing students, experiential learning, qualitative | Schizophrenia + physical disability | The role play simulation required that students interact with public transportation and community resources, while assuming the role of a person with Schizophrenia and a physical disability. Students also selected one or more of the following medical conditions: Multiple Sclerosis (MS), diabetes, hypertension and or vertigo. In addition, all students were assigned to select a functional limitation that might accompany their medical condition, such as a broken arm, significant visual impairment, and mobility impairment requiring of a wheelchair, crutches, or a cane. In lieu of a functional limitation students had the option to select the additional role of being the parent of an infant. Students were asked to take the local public transportation to various community services. However, their first stop was to the bank to cash the Social Security checks. The first community resource to be accessed was the local Mental Health/Mental Retardation (MHMR) clinic for a follow-up appointment and medication management. The next stop was a local agency called People Attempting to Help (PATH) where “in role students” were to ask for hygiene and food items. | 1 clinical day | Immediate | Experienced empathy, sincerity, and caring. | Reflection and creation of an aesthetic expression | Evoked an array of emotions in the students, from feelings of indifference and preconceptions, to an overwhelming sense or emotion of caring. Feeling of loss of autonomy, voiced a realization of their blessings, and reflected on the bounties of access to personal transportation and communication technology. Students also experienced a correction of their preconceptions and misconceptions concerning “bus people.” Recognized the value and necessity of community interdependence and assistance. | "In conclusion, data from the journals suggests that these nineteen students were transformed by this learning experience, gained increased self-awareness, greater insight to another, and a deeper and more meaningful perspective as a result of the day that they spent walking in another’s moccasin. These students had the rare opportunity to step outside of self to see another’s perspective. As one student eloquently stated, “when I become a nurse I will always remember what I have learned (from ‘A Day in the Life’) when caring for my patients.” The authors hope that further evaluation will occur, and that other faculty will report on short and longer-term outcomes of “A Day in the Life.”." | Waldo N, Hermanns M, LuAnne Lilly M. “A Day in the Life”: A simulated experience. J Nurs Educ Pract 2013; 4: 88–95. | ||||||||
73 | 69 | (Warren-Boulton et al., 1982) | Qualitative study | 1982 | USA | Registered and licensed practical nurses, dietitians, other health professionals | Examine participant adherence to the components of the regimen, identify specific adherence problems, and determine how the experience influenced the patient/clinician interaction, to assess the subjects' ability to make insulin adjustments in response to varied urine test results, and to eat prescribed meals and snacks. | 65 | - | Diabetes | The specific routines covered daily subcutaneous injections of 15 U of saline solution in different sites, urine testing 4 times a day, recording results, and calculation of and adherence to a meal plan. Each person was given sterile saline solution, disposable U-100 insulin syringes of different sizes and types, alcohol wipes, a 2-drop Clinitest kit. During the program, participants calculated their own meal pattern, using the American Diabetes Association exchange system. | 4 days | 7-16 months | Improved participant sensitivity to diabetic patient adherence problems and increased ability to effectively counsel patients and family members. Changed focus in many participants from concern and difficulty with self-injection early in the experience, to frustration with the diet and urine testing components as the simulation progressed. | Evaluation form, discussion, questionnaire | Related to the time-consuming aspect of the regimen and the constant need to be planning ahead during each day, often requiring reorganization of lifestyles. Trouble finding the time to do urine tests, give injections, and plan and eat all their meals in addition to handling unexpected occurrences, such as traffic delays or car troubles. a loss of spontaneity in daily activities. Fear of self-injection and initial difficulty in performing the technique. A better understanding of the many problems diabetics experience in attempting to adhere to a manage- ment regimen. Overwhelmed with the lifestyle adjustment needed to complete the tasks of the regimen. More realistic expectations of their patients and a less judgmental response in regard to nonadherence. Recognized the importance of allowing patients the time to learn and integrate the regimen into their lives, as well as the need to periodically provide contact for reviewing the details of the tasks involved, and support or encouragement for continued adherence. | "In summary, a carefully conducted experience such as simulating diabetes routines is an effective educational tool for helping health professionals to recognize and explore feelings generated by the experience, and to develop greater sensitivity to the complexities of adherence to a therapeutic regimen. Further simulation exercises such as this may benefit from the incorporation of blood glucose testing with some "built in" positive results requiring the application of a formula for adjusting insulin dosages. Although individuals may have an intellectual appreciation of a patient's experience, a different level of knowledge is gained by active participation in that experience. By living a lifestyle expected of persons with diabetes, health professionals are able to acquire insight into the unique circumstances of the patient, to develop more realistic expectations of patients, and to recognize the importance of ongoing education and emotional support to enhance regimen adherence." | Warren-Boulton E, Auslander WF, Gettinger JM. Understanding diabetes routines: A professional training exercise. Diabetes Care 1982; 5: 537–540. | ||||||||
74 | 70 | (Welborn & Duncan, 1980) | Pilot study | 1980 | Australia | Doctors, nurses, dietitians, occupational therapists | Improve hospital staff awareness of the routines of management of insulin-dependent diabetes, provide an evaluation of the Diabetic Unit's teaching program and improve the teaching service for patients. | 12 (11) | - | Diabetes | The respondents underwent teaching in urine testing and recording results, twice daily "insulin" regimen, and diet involving regularly spaced carbohydrate in meals and snacks. Each signed an agreement that, within the semester at 72 h no- tice, he or she would attend the nurse educator for instruction and would immediately thereafter simulate an insulin-dependent diabetic person's life for 7 days, with respect to twice daily urine tests, twice daily pseudo-insulin injections, and a dietary regimen. The agreements were understood to be binding regardless of occupational or domestic circumstances, thus mimicking the unheralded onset and diagnosis of the disease. | 1 week | Immediately | Increased awareness of the education nurse's role and expertise in the management of diabetic patients. Enhanced confidence in dealing with patients' practical problems, a sense of more uniform approach in management, a realistic acquaintance with the problems of compliance led to greater empathy between staff and patients. | Debrief, no formal assessment | The need for early rising to perform the initial void, and the difficulty in producing the second sample within half an hour in the course of morning activities. Having to eat regular snacks between meals, an unaccustomed habit. Difficulties were encountered obtaining low-calorie drinks and saccharin in hotels and restaurants. greater insight into the minutiae of the diabetic life especially was obtained. need for privacy for self-injection was generally acknowledged. Shift work, social occasions, and family activities resulted in occasional but manageable difficulties. | "In conclusion, we recommend role-playing experiments of this nature for all therapists involved in the management of diabetic patients. The educational impact of such projects is substantial even for those with many years of involvement with the clinical aspects of diabetes. This approach for the education of staff members may be extended to other areas of therapeutic intervention, including simulation of various dietary regimens and of home monitoring of blood glucose levels. Our study indicates that participants in such experiments uniformly gain insight into everyday problems that confront patients and thereby achieve empathy and greater confidence in management." | Welborn TA, Duncan N. Diabetic staff simulation of insulin-dependent diabetic life. Diabetes Care 1980; 3: 679–681. | ||||||||
75 | 71 | (Westberg et al., 2010) | Mixed-methods study | 2010 | USA | Second & third-year pharmacy students | Assess the impact of an elective diabetes course on student pharmacists’ skills and attitudes about diabetes management. | 84 | Diabetes, simulation, active learning, elective, survey | Diabetes | Students completed daily insulin injections, glucose checks, carbohydrate counts, and kept a daily log while simulating the life of a patient with Type 1 diabetes. Each student received a glucose meter, test strips, a lancet device, lancets, and alcohol swabs. In addition, they received 30 insulin syringes and a 10 mL multiple-dose vial of bacteriostatic normal saline for injecting ‘‘insulin,’’ along with a sharps container for disposing of used syringes, glucose tablets for a simulated hypoglycemic event and they were given a bag of glucose values typical for a person with Type 1 diabetes. Students checked their blood glucose and injected normal saline as their ‘‘insulin’’ 4 times daily: a basal insulin dose at bedtime and 3 doses of rapid-acting insulin with meals. To simulate a need for dosing adjustments, random piece of paper from the bag of glucose values during each glucose check was drawn. Students kept a daily log that included: actual glucose, ‘‘drawn’’ glucose, carbohydrates consumed, insulin dose for carbohydrates, insulin dose for current ‘‘drawn’’ glucose value, and total insulin dose given (for 3 meals daily). | 1 week | Immediate? | Improved skills and confidence in their ability to teach patients. | A preintervention and postintervention survey, 3-5 page reflective paper, diabetes logbook, reflective discussion, weekly quiz | Basic attitudes toward diabetes did not change significantly. The mean scores decreased, indicating that the level of disagreement with that statement increased. The remaining statements focused on self-report of students’ confidence in performing diabetes management skills and teaching diabetes management skills to others a significant increase in confidence in performing these skills. The tendency for students to be slightly less confident teaching the skills compared to doing the skills themselves remained constant. | "A diabetes elective, which included a 1-week simulation of living as a diabetic patient, was an effective teaching method to increase students’ confidence in performing and teaching diabetes self-management skills. This diabetes experience elective course provided students with the opportunity to immerse themselves into the life of a patient with insulin-dependent diabetes. Results of a preintervention and postintervention survey indicated that students’ confidence increased in their ability to complete and to teach others basic diabetes management skills, such as glucose monitoring, insulin adminis- tration, carbohydrate counting, and appropriate insulin dose adjustments." | Westberg SM, Bumgardner MA, Brown MC, et al. Impact of an elective diabetes course on student pharmacists’ skills and attitudes. Am J Pharm Educ 2010; 74: 1–7. | ||||||||
76 | 72 | (Whitley, 2012) | Qualitative study | 2012 | USA | Pharmacy students | Develop and integrate an active-learning diabetes simulation into an advanced pharmacy practice experience to improve pharmacy students’ empathy toward patients with diabetes mellitus, better prepare students to provide patient-centered diabetes management services, which may likely enhance the provision of clinical pharmacy services for other disease states as well. | 39 | Diabetes mellitus, advanced pharmacy practice experience, active learning, simulation, public health, empathy | Diabetes | Students simulated the experience of having diabetes mellitus by conducting activities commonly prescribed to those with this disease state for 7 days. They used a glucometer, 25 testing strips, lancets, a lancing device, a carbohydrate counting book, a demonstration device, and a placebo insulin pen and a standardized documentation log was also provided for each student’s use. On their respective predetermined days, students were expected to begin incorporating: check feet daily for circulation, sensation, and integrity; initiate an exercise routine consistent with the American Diabetes Association recommendations; quantify the number of carbohydrates eaten at each meal or snack; and self-monitor blood glucose twice daily before eating meals, 2h postprandially 4 times /week, and at least once at 3:00 AM. To create an elevated blood glucose value students added 100 mg/dL to each self-monitored blood glucose value recorded. Based on an insulin sensitivity factor of 1:10 students were to calculate the correct rapid-insulin dose. Using the placebo insulin pen, students administered the calculated number of units into the demonstration device before eating 2 meals daily and postprandially, as necessary. | 1 week | within 4 days | Development of empathy. More consideration and realistic views when providing self-care recommendations to patients and more understanding and compassion when patients did not adhere to all aspects of the prescribed therapeutic plan. Improved ability and comfort level with performing technique-related tasks. Challenging experience with ability to identify hindrances associated with maintaining self-management efforts for a mere 7 days and reflection on a likely inability to do so for longer periods of time. | Standardized diabetes log and narrative reflection | 95% developed empathy, 97% found the experience beneficial, and 67% improved their ability to relate to and counsel patients. 95%found difficulty adhering to the regimen. 69% decided to modify their personal habits to become healthier. developed empathy, found the experience beneficial/useful, developed new motivation to change personal lifestyle, expressed difficulty with regimen adherence, and identified helpful methods/tools for improving adherence. Improved ability to counsel/ relate to patients. Found helpful: carbohydrate-counting book or electronic application, meal repetition, and setting reminders/alarms. | "Inclusion of the 7-day active-learning exercise greatly impacted student pharmacists’ self-reported empathy toward and ability to relate to patients with diabetes mellitus. Completion of this experience may result in long-lasting personal behavior modifications. Implementation of this 7-day experience provided many benefits for fourth-year PharmD students, including increased self-reported empathy for patients, improved ability to relate to patients, increased comfort level with patient interactions, and heightened awareness toward and bolstered behavioral modifications related to personal health habits. The experience may be altered in the future to enhance adherence measures and to compare medical students’ responses to those of student pharmacists." | Whitley HP. Active-learning diabetes simulation in an advanced pharmacy practice experience to develop patient empathy. Am J Pharm Educ 2012; 76: 1–7. | ||||||||
77 | 73 | (Wieland et al., 2014) | Qualitative study | 2014 | USA | Bachelor nursing students | Investigate the experience of baccalaureate nursing students with the clinical simulation of hearing distressful voices and derive themes based on their written reflective responses. | 74 | - | Auditory hallucinations | The first workstation, the “cognitive center,” consisted of word and number find forms, each to be completed in 3 minutes. At the second workstation, students were interviewed by a “psychiatrist” (role played by a another student) who asked questions based on the mental status examination, such as “Tell me what the proverb ‘Still waters run deep’ means,” or “If you were lost with no money in a large city, what would you do?” At the third workstation (i.e., the “employment office”) students were required to complete a complex job application within a 10-12 min time-frame. Audiocassette players with headsets were purchased, and the VSE was downloaded. Students were requested to keep the headsets on and actively engage in the experiences. They were instructed to not talk to other students, except for those involved in the simulation experience. | 1h | Immediate | Increased learning and understanding of individuals experiencing auditory hallucinations, feeling frustrated, uncomfortable, and having a difficult time concentrating while listening to the voices. Reflections in the current study did not evoke statements regarding fighting stigma. Identified interventions on their own understanding how distracting and, at times, derogatory the voices can be. Participants proposed speaking more slowly to patients and giving them time to respond while at the same time, being certain the patient understood what the nurse was saying, providing validating, positive comments to counter the negative demeaning voices. | Reflective evaluation | Attempted to perform tasks, but feeling as if they could not concentrate or focus, overwhelmed by the experience, as the voices competed with the activities and people in the environment who were giving directions for the assigned activities. Voices laughing at the students were described as annoying and irritating. Delineated bodily symptoms (e.g., headaches, anxiety, light-headedness). Described how they perceived hearing distressing voices to affect activities of daily living. Learned to develop more patience with individuals hearing voices. gained an overall greater patience, appreciation and understanding of what clients who hear distressing voices experience on a daily basis. | "The clinical simulation of hearing distressing voices is an exceptional learning experience for BSN students because it increases active learning and provides students with the experience of hearing distressing voices similar to what patients with psychosis actually hear. This experience, as compared with lecture-oriented content, was deemed to be superior by the current researchers. Most importantly, the VSE demonstrated the effect it has on affective learning of students—transforming their societal biases into more positive professional attitudes toward patients. The VSE enhanced students’ abilities to be empathetic, understanding, and compassionate toward a vulnerable population, specifically individuals with chronic and persistent mental illness. The research findings exemplify the benefit of VSE in the preparation of BSN students for their psychiatric-mental health clinical rotation." | Wieland D, Levine C, Smith J. Hearing distressing voices clinical simulation ‘Life Changing’ Experiences of Psyciatric-Mental Health Nursing Students. J Psychosoc Nurs Ment Health Serv 2014; 52: 42–51. | ||||||||
78 | 74 | (Wilson et al., 2009) | Mixed-methods longitudinal study | 2009 | UK (NI) | Healthcare professions within the neurorehabilitation inter-disciplinary team | Evaluate the impact of training on reflective clinical practice. | 78 | Simulation, exercises, neuro-rehabilitation, brain injury | Neurodisability | The exercises took place across 7 ‘stations’, each of which provided experience of a different neurodisability presentation. Visual impairment - participants were asked to copy a short passage from a book wearing left-sided hemianopia simulating spectacles, thread a needle wearing blurred vision spectacles, walk an obstacle course with tunnel vision spectacles under controlled light conditions. Sensory impairment - subjects were asked to identify the following using their non-dominant hand while wearing a thick gardening glove in a container of lentils. All participants wore a blind-fold and were asked to identify the following (solely with touch): soft toy, glove, sock, spoon, shoelace, comb, toy car, toothbrush, fork, key, pen, razor (with safety guard in situ), coins – £2, 2p, 5p, 1p, face cloth and tactile dominos (to be matched up). Dyspraxia - using a mirror and a star with a wide double border, participants were asked to use their non-dominant hand to trace a 3rd line within the double border using the reflection of the star in the mirror only and to write their name using their non-dominant hand, looking only in the mirror, so that it appeared legible on the page. Immobility - participants were seated in a manual wheelchair and pushed at speed and roughly over a range of surfaces including sand and gravel then used a powered wheelchair whilst wearing right-sided hemianopia-simulating spectacles. Divided attention/overstimulation. Participants were asked to complete a word search puzzle. Loud background noise was played including a radio (between stations), a phone ringing and a facilitator continually interrupting or aggravating the participants.Sustained attention - participants were asked to correctly identify an alphanumerical sequence. Each time, participants heard the specific digits ‘55’ at the end of the two letter or three-digit announced tickets, he/she was asked to remember and to record the two letters immediately before it against an alternating background of visual and auditory non-contingent distractions (arranged to mimic the effects of internal distractibility). Dysphasia. - the demonstrator at this station communicated a series of instructions speaking in a foreign language (Dutch) with no gestures. Participants were asked to interpret what had been said. The demonstrator repeated the instructions using picture cards asking to interpret what had been said. | 3h | Immediate & 3-months after | Experienced some degree of distress and frustration. Increased empathy towards patients and suggested that the exercises helped to inform the practical ways they dealt with patients also made some real changes for the care the patients receives, was a very positive unexpected outcome. | Questionnaires, debrief | Increased self-reported empathy and concern for patients. Helped inform practical ways of working with patients. Referred to a number of emotional reactions including perceived difficulty, fear, sense of dependency, frustration, anxiety and irritation or annoyance associated with taking part in the simulation exercises. Greater awareness or increased empathy towards patients, that they previously underestimated the effects of brain injury, and had new insight into the difficulties associated with such acquired impairments. Helped to inform practical strategies for helping patients, including approaching a person with hemianopia from their line of vision, taking time to tell the patient who the professional is and what they are doing. Highlighted changes in practice including pushing a patient more slowly in a wheel- chair, giving small amounts of information to patients and ensuring it is understood before moving on. | "Simulation exercises, when organised with the aim of developing insight and empathy can result in positive outcomes for those who take part. Simulation exercises as an integrated learning tool for staff within healthcare settings should be provided. Although there are a number of notable limitations to the current study, the results nonetheless attest to the positive benefits of this training, both in terms of increased empathy for those with neurodisability, but also importantly, by informing more appropriate practice within the interdisciplinary neurorehabilitation team. The current study underscores the potential utility of introducing simulation exercises as part of routine training for professionals working with those with neurodisability. Within the service context, the next step in this process is to conduct consultations with service user groups and service managers to disseminate the study results and plan the next steps. A 1-year follow-up would also be a useful method of examining the long-term utility of simulation exercises. It may be that top-up training could be helpful in order to maintain the positive benefits noted by staff from participation." | Wilson FC, Nelson S, Downes C, et al. Effectiveness of neurodisability simulation training for NHS staff working in brain injury rehabilitation. Disabil Rehabil 2009; 31: 1418–1423. | ||||||||
79 | 75 | (Yu & Chen, 2012) | Quasi-experimental study | 2012 | Taiwan | Nursing assistants | Test the effects of the Elderly Simulation Program on nursing assistants’ knowledge about aging, attitudes toward older adults, and the motivation to care for older adults in nursing homes. | 83 (43) | Education program, nursing assistant, nursing home, older adult, on-the-job training | Old age | Participants wore the elderly simulation devices, simulating the degenerating physical functioning that older adults typically experience: a pair of sponge ear plugs (deteriorated hearing); a pair of specially designed glasses (poor eyesight); three layers of gloves on one hand (decreased sensitivity and hand flexibility); a vest with two 3-pound sand bags in the front pockets to increase their weight and create spinal deformities; cotton cloth wrappers on elbow, knee, and ankle to simulate decreased flexibility of the joints’ range of motions; and two 5-pound sand bags on one wrist and ankle to simulate the slow movements of arms and legs. Because of safety concerns, the elderly simulation device was worn on only one side of the body. Because the simulation program was potentially stressful. Team members acted as caregivers, providing the necessary assistance and protection, leading them to realize how important the attitude of the caregiver is to the older adult. Group C members acted as a rusher to urge patients to speed up their movements to create the scenario of being pushed and hurried to perform those daily activities that older adults often encounter. In the simulation process, the participant who acted as the older adult had to complete more than 10 necessary daily tasks, such as sitting in a wheelchair, filling out some forms, using chopsticks, going to the bathroom, reading a newspaper, going up and down stairs, and getting up from bed. | 1h | After 4 weeks | Significantly improved knowledge about aging, attitudes toward older adults. | Nursing Assistants’ Knowledge About Aging Scale, Nursing Assistants’ Attitudes Toward Older Adults Scale, and Nursing Assistants’ Motivation to Care for Older Adults Scale, debrief | Knowledge about aging and attitudes toward older adults significantly improved (all P < .001). Greater knowledge of aging (P < .001). Worse attitudes toward older adults than the experimental group (62.4 ± 6.1). Significant improvement in knowledge about aging and attitudes toward older adults (t = -3.6, P < .001). | - | Yu CY, Chen KM. Experiencing simulated aging improves knowledge of and attitudes toward aging. J Am Geriatr Soc 2012; 60: 957–961. | ||||||||
80 | 76 | (Zagar & Baggarly, 2010) | Mixed-methods study | 2010 | USA | College of Pharmacy students | Implement and evaluate a simulation activity and related assignments within a geriatric elective to teach pharmacy students about the medication management difficulties experienced by low-vision patients, provide students with a better understanding of the various medication-related difficulties faced by visually impaired patients and to expand students’ opportunities to develop patient- and population-specific services related to low vision. | 18 | Simulation, medication management, adherence, geriatrics | Low-vision, medication management | Students wore welder’s goggles with lenses that had been altered to simulate low-vision conditions of glaucoma, cataracts, macular degeneration, diabetic retinopathy, and retinitis pigmentosa, while manipulating pills, prescription vials, and other medication-related materials. Patients interact with medications on a regular basis. Students read prescription labels, auxiliary labels, and patient information leaflets; distinguished the color, shape, and size of, and fine markings on tablets and capsules; poured doses of liquid medications (colored simple syrup) into spoons; and measured doses of medications in syringes (without needles). Students only manipulated medications; no medications were ingested. Students were instructed to look at all parts of the prescription label, including the number of refills and expiration date, and to approach reading the label as a patient would, word-for-word, without relying on pharmacy knowledge that might allow them to infer the directions for a particular drug. | 1,5-2h | Immediate | Gained a personal understanding of the medication management difficulties of patients with a variety of low-vision conditions. Ability to recognize the challenges of low-vision patients, compare and contrast medication management difficulties among low-vision conditions and the need for pharmacists to intervene on their behalf. Recognition ‘‘low vision’’ differences between individuals and that some medication-related tasks were more difficult for some low-vision patients than others. Medication management tasks presented greater difficulty for those with impaired central vision and therefore these patients require more assistance from the pharmacist. | Worksheet at every station, perception survey, reflective journal exercise | Reflected on experiences in journals and developed modalities to improve low-vision patients’ access to prescription information. Indicated that students were able to identify, differentiate among various low-vision medication management difficulties and recognize the challenges encountered. The difficulty index scores were significantly higher for macular degeneration, cataracts, and diabetic retinopathy than with glaucoma and retinitis pigmentosa. There were significant differences in the degree of difficulty reported for performing various medication-related tasks with each simulated disease. The most difficult tasks for all diseases were reading patient information leaflets and drawing correct doses of medications in a syringe. | "Through this low-vision goggle simulation exercise and other activities, students were able to identify the medication management difficulties encountered by low-vision patients and propose solutions to their drug information access problems. A patient-centered, student-directed learning activity involving simulation of low vision using goggles with altered lenses provided students with hands-on opportunities to experience the medication management difficulties faced by patients with a variety of low-vision conditions. Following the simulation exercise, students were well-prepared to devise ways to improve vital access to prescription information and hopefully help to minimize the risk of medication errors in this population." | Zagar M, Baggarly S. Simulation-based learning about medication management difficulties of low-vision patients. Am J Pharm Educ 2010; 74: 1–7. | ||||||||
81 | 77 | (Zapko et al., 2015) | Pilot study | 2015 | USA | Nursing and radiology students | Examine the effect of using serial simulations with progression through the nursing curriculum. | 157 | Simulation, disaster drill, patient actors, interdisciplinary simulation, nursing education, problem solving | Disaster | Nursing fundamentals students and beginning radiology students served as patients, family members, and patient transporters helping beginning students relate to and learn about the patient experience. Students were presented in class with case scenarios for individual patients in the disaster drill. They researched and devised plans for how they would portray the patient situation. They were also asked to use their creativity to dress the part. Junior nursing students gave hands-on nursing care, which included wound care, and practiced history taking, physical assessment, and therapeutic communication, while the radiology students performed radiologic procedures. Senior nursing students served as disaster team leaders, triage nurses, and charge nurses. They also coordinated with incident command, directed mobilization of resources, managed communication, and attended to public relations issues associated with the disaster drill simulation. High-/medium-fidelity manikins were used in the scenarios; a high-fidelity manikin allowed senior students to participate in a cardiac arrest situation and perform a “full code.” Medium-fidelity manikins were used to portray trauma and obstetric patients. | - | Immediate | Increased self-confidence in caring for patients during a disaster as a direct result of this disaster drill. Greater empathy for patients involved in the disaster. Displayed prioritization of care, clinical decision-making and critical-thinking skills. | Debrief | Displayed critical thinking and clinical decision-making skills. Reported an increase in self- confidence in caring for patients during a disaster, an increase in empathy, and learning by observing others. | "This pilot study revealed that an interdisciplinary disaster drill simulation experience was a positive learning experience for both nursing and radiology students. Incorporating students from all levels of both programs in the simulation provided students from both programs an opportunity to understand a discipline outside their particular field of study. This drill gave all involved students a unique opportunity to learn from each other, with an exchange of knowledge taking place at a student-to-student level under the direction of faculty. Furthermore, the experience allowed sophomores to witness the performance of their upperclass counterparts and allowed juniors and seniors to assess their own growth while recognizing their gaps in knowledge. Research into the use of these types of simulations as a teaching strategy could prove a valuable addition to the literature. Our first two disaster drills were well received by faculty and students and proved to be beneficial. We will now conduct research on overall student perceptions and outcomes of learning after participation in a series of interdisciplinary disaster drills. Each year, students will fulfill a different role in the disaster drill. Course and level competencies will be matched to the roles assigned to the students. Our research will look at changing outcomes and perceptions over a three-year period as students progress through the program and participate at each level. This interdisciplinary program incorporating nursing and radiology students from all program levels working with each other, faculty, and disaster management professionals from the community provides an innovative method of using simulation for today’s nursing students." | Zapko KA, Ferrante M Lou, Brady C, et al. Interdisciplinary disaster drill simulation: Laying the groundwork for further research. Nurs Educ Perspect 2015; 36: 379–382. | ||||||||
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