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Interprofessional Simulation Cases for Cultural Competence


Background of Project

The Center for International Rehabilitation Research Information & Exchange (CIRRIE) develops curricula and educational materials on cultural competency for rehabilitation service providers working with the growing population of immigrants in the U.S. CIRRIE considers knowledge of cultural views on disability and rehabilitation to be a type of international knowledge of direct benefit to service providers working with foreign-born clients.

Previous work focused on workshops on "culture brokering" for in-service training, a monograph series, and curriculum guides. The traditional approach of training rehabilitation professionals in cultural competence is typically classroom based instruction utilizing interactive case studies. This approach provides background ability, but seldom involves the learner in synthesizing and integrating what has been taught in relation to the real life clinical environment. Simulation provides opportunities to create clinical events that are infrequent occurrences in clinical field work and bring to life paper cases. Simulation bridges the gap between academic preparation and the work environment of rehabilitation. This project creates simulated clinical encounters with manikins and standardized patients for cultural competence training of rehabilitation students or providers.

Introduction to Use

Simulation is a powerful educational tool for rehabilitation students and providers to gain cultural competence. Participants in simulation consistently rank their satisfaction extremely high for the ability to implementing learning experiences into clinical practice. Planning and practice is key to achieve outcomes. Case scenarios were developed for interprofessional teams of rehabilitation providers. The teams must make decisions and take appropriate actions in real time, sometimes together and some times separately.

Describe the manikins

Simulation can be provided with high fidelity manikins or standardized patients. Manikins provide the ability to alter the level of learning challenges that may not be available using a standardized patient and allow consistent repeatability of the learning challenges. The level of technological support influences the level of realism and if not considered by the developer in the planning, can result in alterations in fidelity. A high-technology scenario by definition includes equipment in good working order. To support realism the equipment should be the same as that used in real clinical practice. If the equipment does not work this can alter the fidelity of the experience. Highly technical scenarios can also include sophisticated mannequins such as SimMan™ and SimInfant™. Manikins have evolved as a result of computer technology and appear more human in appearance and scale than older models. They have electronic capabilities that mimic human functions including voice and body system functions. A few examples of the body functions are blood pressure readings, heart sounds, and the ability to blink. The scenario developer must plan for the amount of technology and the amount of student assistance to be made available prior to conducting the scenario. Assistance may come in the form of answering questions and teacher availability during the scenario.

When the manikins are used, a facilitator speaks and the manikin comes alive. The manikin can also be programmed to present with certain medical conditions or change in vitals or appearance. Standardized patients (SP) are lay people who can be trained to represent a multitude of cultural challenges and potential barriers. "Confederates" or Actors are built into the scenarios to add other players in rehabilitation care such as family members or another health care professional. Confederates can be played by facilitators, Standardized patients or other students/providers.

Scenarios developed embed patient issues of recent immigration for medical services. Cultural challenges of language barriers, use of translators, priorities of family, and beliefs of rest over rehabilitation are some examples.

Each scenario will run approximately fifteen minutes in length, with students/providers directly involved or watching the live feed. Each scenario is immediately followed by a debriefing session that lends to self reflection and peer feedback. The debriefing session usually takes 30 minutes depending upon the discussion raised. A facilitator leads the debriefing session asking open-ended questions such as, "what went well in that encounter" or "how do we best address their beliefs"? The session proceeds with the participants, both those that were active in the encounter and those who observed, giving feedback and raising more questions to the group. The debriefing session is the time for the entire group to problem solve together with the facilitator guiding. Each scenario is repeated with slight alteration for mastery of skills. This repetition is very important as it allows participants to immediately practice skills gained and have confidence about the utilization of these new skills.

Concepts evolve about how to utilize an interpreter, dealing with patients of different cultures, importance of communicating with other disciplines and how to involve patients and their families in their care. Students report improved interactions with foreign born patients following a three hour simulation experience of approximately three scenarios.

Case Scenario Components


Learners: Will dress in their professional attire with name tags and have with them their tools of trade. Will be given a brief synopsis of scenario from the facilitator and timing to enter the scenario stage.

Facilitator: Person who will be the lead teacher during the encounter and maintain the scenario integrity. The facilitator will determine who will play what roles, will usually play the voice of the manikin, will train the Standardized patients and will lead the debriefing immediately following the scenario. The facilitator will coordinate with the technician (for manikin use) for staging etc., orient learners to the environment, manikin, resources available and set ground rules for the session. [Calls, "wrap" when scenario is complete.]?

Confederate/Actor: Person who will dress and play the role of a health care professional or family member or other participant. Confederates will get their role and directions from the facilitator.

Standardized Patient or Manikin: will play the patient in the scenario, will be the main focus, will portray the case as accurately as possible but will be trained to adlib when necessary to respond to learners.

Scenario Contents

The cases are organized into the following sections:

Main Focus: In general, what the learners can be expected to be exposed too during the scenario.

Performance Measures: Based upon [framework threads]?. Each measure will fall under either

  1. Cognitive (C)
  2. Technical (T) or
  3. Behavioral (B) thread

The performance measures clearly define the desired actions of the learners. The measures should be easily identifiable by the learner group in the debriefing session and video review. They are measurable by either a physical action, a verbalization or step in the process.

Synopsis of Scenario (S.O.S) : Brief description of scenario to be told to the learners. Not a case study, just a snapshot in time, designed to drive the performance measures. Will not include any information on progression of events or past events that learners will need to obtain. Should include setting, brief relevant history, patient presentation, roles and interactions, tone, environment and general progression of events.

Imbedded Challenges: As the name states these are the "challenges" the learners will experience. Imbed to achieve the desired actions of learners. Can involve patient or confederates.

Skills/Tasks/Procedures: Are related to the performance measures and patient care management. Need to be done in less than 10 minutes, should limit to less than 5 in each scenario.

Learner Roles & Staging: will specify the role of each and staging (timing) of entrance into scenario and the basic role of each. Will identify specific information to be given to each learner as this may vary from the SOS.

Confederate Roles & Scripting: Should be relevant to the experience and will be given specific information on body language and verbal language. Can portray many attributes that can prompt a learner response.

Patient Information: A detailed case study that is not shared with the learners prior to the scenario but guides the experience. This section should include the patient's photo to add realism.

Technician Staging Directions: Gives specifics for the staging of the environment, the manikin or Standardized patients. Staging is important for suspended disbelief and to have equipment ready and available to the learners.

Progression of Events: Usually a 10-15 minute snapshot of how the scenario should progress, in 5 minute blocks of activity. The events may include physiologic changes made to the manikin or Standardized patients reporting symptoms. Outlines when cues or confederates are prompted to change the events. Details performance measures in logical order.

Integrated Debriefing: Outlines discussion points that should be brought up during the debriefing (usually by the facilitator). Will prompt video review for discussion points during particular events. Will help to identify performance gaps.

Take Home Messages: May list relevant points that should clearly be articulated to the learner group, if they haven't been already. May also contain references that learners can access to support the main focus of the encounter.