Activity: Humanising Technology: Technological prescription and associated dilemmas

Learning outcomes

By the end of the activity, students should be able to:

• Identify the dilemmas associated to technological health devices
• Calm down an anxious patient and generate a relationship of trust and shared decision-making in terms of treatment and other medical procedures
• Work in an interprofessional team and establish a functional and coordinated distribution of roles and responsibilities

As regards transversal skills, students should be able to:

Interpersonal and socio-emotional skills:

• Express ideas clearly and fluently
• Use precise and descriptive/content-specific vocabulary to enhance the topic or message
• Share information in an organised and interesting way
• Share an analysis of the main message to interpret, synthesise and/or evaluate the meaning of the content in order to draw a logical conclusion about the topic
• Show empathy and use non-verbal communication and active listening
• Self-reflect, evaluate one’s own actions and emotions, and take responsibility for own actions
• Perform tasks efficiently and carefully
• Persevere in the face of difficulties
• Develop positive and emotionally safe interaction and develop and co-create teamwork
• Reflect and manage emotional and self-regulation, and show empathy in professional relationships
• Work cooperatively with others
• Develop an empathetic leadership by understanding the needs of others and being aware of their feelings and thoughts, and to facilitate collaborative and participatory problem-solving
• Create a non-discrimination atmosphere
• Facilitate conflict resolution, remain calm under pressure, and control one’s emotions in conflict situations
• Be willing and able to understand people from different backgrounds and embrace diversity

Critical and creative thinking:

• Identify and deal creatively with unexpected, unforeseen, and complex situations that can be exploited, and to evaluate different solutions
• Acquire, process, produce, and evaluate information critically and from the perspectives of different fields and decisions, taking into account both individual and community perspectives
• Question norms, practices, and opinions, and to reflect on own one’s values, perceptions and actions
• Develop innovative solutions to answer different questions and to create new and worthwhile ideas; elaborate and evaluate ideas in order to improve and maximise their creative efforts

 

Brief description of the activity

The activity consists of a simulation in which a patient, Johanna Rogers, goes to the Primary Care consultation to check her health status. During the visit, the professionals (students) discover that Ms. Johanna is using a technological device to control her diabetes at the recommendation of her daughters, which is causing her some discomfort. The interprofessional team will have to talk to the patient and explore her needs, while managing her reactions altogether. During this activity, students will mainly work on their interpersonal and socioemotional skills, but they will also need to think creatively and critically to resolve the situation effectively.

 

Activity plan: step by step

 

Before the activity

1. Definition of the case according to the learning outcomes: 

The description of the case must include, at least:

(1) Description of the initial scene and clinical features

(2) Challenge posed to the student

(3) Narrative of the simulated character (especially if simulated with actors/actresses)

(4) Key moments that define the course of the case depending on the actions of the student

 

For this activity, the following case is proposed: 

 

Joanna Rogers is a 68-year-old woman who was diagnosed with type 2 diabetes 8 years ago. Mrs. Rogers is an active woman who can perform her daily tasks independently. She tends to maintain good blood sugar control and treatment adherence, with some variations depending on the time of the year. Today, she comes to the primary care centre for her monthly check-up of her blood sugar levels and general state of health. On previous occasions, she was accompanied by her daughters, who are very worried about her health. But today she came alone.

 

Background:

• Obesity (BMI 27), hypertension, anxiety-depressive syndrome.

Treatment:

• Metformin 1-0-1
• Humalog Mix 25 28-0-22
• Enalapril 20 mg w / 24
• Fluoxetine 20 mg w / 24

Vital Signs: 

• RF: 15x’
• SatO2: 98% (0.21)
• CF: 87x’
• TA: 142/89 mmHg
• Auscultation: Vesicular murmur preserved. 
• Temperature: 36,5ºC
• Blood sugar level: 243 mg/dL
• Glycosylated haemoglobin: 6.3%

 

Mrs. Rogers enters the room and sits in the chair in front of the consultation table. She brings with her a bag in which she keeps a notebook (where she writes down her sugar records), her blood glucose measuring machine, a smartphone and a smart fork. Soon, professionals might discover that the patient hasn’t been following all the recommendations and that she presents abnormal blood sugar levels. When asked, Mrs. Rogers minimises the results and explains that her daughters are so worried about her health (what she thinks is such an exaggeration) that they bought her a smart fork to control her health. The patient is visibly annoyed by this object and tells the professionals that she’s fed up with so many recommendations and food restrictions. 

 

Students are asked to:

 

(a)  check vital signs and the patient’s general health status. 

(b) explore patient’s needs and worries

(c)  enable a trusting communication space in which the patient feels comfortable and non-judged: (i) explore patient’s feelings and emotions, (ii) address questions and worries, (iii) perform emotional containment and regulation, (iv) conflict resolution and negotiation

(d) perform health education recommendations and actions

 

Narrative of the character and case development: 

 

Joanna is a 68-year-old woman. Joanna is an active woman who can perform her daily tasks independently. She is a laughing and cheerful woman who always tells anecdotes: since she retired, she says that she is living a “second youth” and wants to enjoy the time she has left to the fullest. She often tells us that she goes out with her friends and that they even go on trips. Her husband is older than her and has a more sedentary life (you know him because he also visits the same primary care centre), so they often make separate plans, which the two agree upon.

 

While she tends to maintain good control of blood sugar, lately we detected some variations, especially after holiday periods (Christmas, summer, etc.). In the past, when we emphasised to her the importance of keeping control of her diet, she told us that she is fine and that we do not have to suffer so much for her as “nobody dies of an extra ice-cream”. At the last check-up, which occurred right after a holiday period, the record came out quite altered, to which she argued that during holidays nobody cares about health and diet, and that she wants to enjoy family and food. That day, she came with her daughters, who were very concerned about her health. This resulted in a slight fight between them.

 

Today she attends the primary care centre for her monthly check-up, and she comes to the visit by herself. In fact, you suspect that she has requested the visit during working hours so that her daughters cannot accompany her. She is dressed with modern and colourful clothes (street outfit) and nice make-up (it is evident that she takes care of her appearance). When entering the room, as always, she greets you with an endearing smile and tells you that she has just arrived from Sicily where she went with her bingo friends. 

 

The health professionals will have to ask her to show them the blood sugar registers. If they don’t ask her to do so, she will do it anyway. She opens her notebook with all the records written down and extends it, proudly, to the professionals. Before the professionals have time to read the registers, Joanna starts explaining how well she did follow the diet and all the recommendations. Notebook records as well as glycosylated haemoglobin denote that notebook tracking is not entirely adequate. If the professionals confront the results with Joanna, she will first deny them by attributing it to the fact that the machine is wrong or that she does not understand why the results are not correct. It won’t take too much insistence for her to acknowledge that in Sicily she didn’t follow the diet (she may even remember how good the spaghetti frutti di mare that she ate in front of the harbour were). Given this acknowledgement of non-compliance with the diet and other recommendations, different situations may occur:

 

• If the professionals start preaching to Joanna reiterating the importance of diet and the severity of the implications of decompensating diabetes, she will get angry and accuse them of being just like their daughters and making her life bitter.
• If the professionals are empathetic and ask questions to comprehend Joanna’s values ​​and priorities, she will accept it and answer the questions. She will explain that for her, it is essential not to stop enjoying life, since she is getting old and doesn’t know how long she’ll be healthy enough to keep her lifestyle.

 

So far, the case should not take much longer than 5–6 minutes.

 

Following the thread of the previous scenarios, Joanna will explain that she feels overwhelmed and controlled by the issue of diabetes. She will tell the professionals that after the last visit, her daughters bought her a smart fork that calculates the type and amount of food that she is ingesting. The worst thing, she says, is that the information recorded by the fork is sent directly to the phones of their daughters, who downloaded an app. Her daughters told her that it is for her own good, but she tells us that she finds it a violation of her freedom and that this issue has already triggered some conflicts within the family. She also explains that they have downloaded an application in her own mobile phone (she can take it out from her bag, showing it insistently to the professionals and with evident difficulties to manage its navigation) that does not stop making dietary recommendations. Joanna can also explain that she found a way to cheat the smart fork so that the information her daughters receive tells them that she is following the diet, when she is actually not doing so. In fact, she tells us that her daughters discovered this cheating some days ago and that they are controlling her even more compared to what they did before.

 

Given this situation, professionals may adopt different positions: 

 

• In the event that the professionals adopt a punitive attitude in which they sermonise the patient or insistently reiterate the recommendations, Joanna will get angry by closing herself to keep speaking and even threatening them by telling she won’t come to her visits again. If not resolved, she might stand up and leave. 
• In the event that professionals are hesitant or excessively reinforcing her position, Joanna will be manipulative trying to bring professionals to her field (forcing them to accept that life should be enjoyed to the fullest, that no one should exercise control over her and that above all she has the right to preserve her freedom to choose what to do with her life, etc.). If not resolved, Joanna will take her phone and send her daughters a voice note telling that even the health professionals think the smart fork is an abominable idea.  
• If the professionals choose to negotiate, she will show resistance at the beginning but will end up accessing and participating. If properly asked, she would accept a visit with her daughters to negotiate altogether. 

 

2. Preparation of the physical setting

 

Simulation room equipped as a primary care room with the necessary and typical material for a unit of these characteristics, correctly labelled and ordered. It also can be provided with any other medical equipment and monitors required for the case resolution. The patient’s clinical history can be found either in the computer or in a paper folder. Finally, it must be equipped with a camera and microphone system that allows live broadcasting of the scene to the debriefing room.

Debriefing room separated from the simulation room. It has to be equipped with enough resources to be able to see and hear live what is happening in the simulation room. Likewise, it must allow all participants to be integrated into the conversation, avoiding physical barriers that prevent everyone from seeing each other face to face. 

Simulation control room from which the development of the case is controlled, and the case is broadcast. It is important that the teaching staff or simulation technicians know the computer equipment that is being used. 

3. Definition of the roles of participants

 

Role of the students. Students will be divided into two groups: those who get into the simulation room and try to solve the case (i.e. enact the role of health professional), and those who observe their peers trying to solve the case. All students will participate both in the pre-briefing and debriefing phases of the activity. The group will decide who gets into the simulation room and who stays at the observation room. 

Things to take into account prior to the activity:   Context. You should make sure that the activity is appropriate for the number of students you have, as well as for the learning objectives of the subject in which it will be implemented Materials necessary for its implementation. Make sure that you have a proper primary care simulation room with a proper camera/microphone system. The observation room should have a screen to watch and listen to the development of the case real-time and big spaces to perform the pre- and de-briefing phases. Check whether you have all the consumable and non-consumable materials that will be used during the activity, from printed sheets with the description of the case to the materials of the primary care simulation room. Finally, make sure that you provided students with all the necessary information about the case. Human resources necessary for its implementation. In simulation activities, at least two teachers should be available with knowledge of how to perform simulation activities. You may also need to hire an actress to perform the role of Ms. Rodgers.

 

During the activity

Step 1. Pre-briefing. The pre-briefing phase is devoted to generating an emotionally-safe space, wherein students feel comfortable to perform the activities they are required without being judged, show their emotions as these emerge, and rely on the group for any source of support. The teacher(s) should be perceived by students as part of the group. To know more information about how to organise this phase, see the Methodological guide. 

Step 2. Case development. For the case development phase, the group will need to choose the students who go into the simulation room and those who stay at the debriefing room. The latter will see their peers trying to solve the case. Before the students enter the simulation room, the case is briefly presented to the whole group. 

Joanna Rogers is a 68-year-old woman who was diagnosed with type 2 diabetes 8 years ago. Joanna is an active woman who can perform her daily tasks independently.

Even though she tended to maintain a correct blood sugar control, with some variations depending on the time of year, in the last visit we noticed that she wasn’t following the dietetic recommendation. Today she has her appointment in the primary care centre to check his blood sugar. On other occasions, she was accompanied by her daughters, who are very worried about her health. But today she came alone.

Enter the primary care room and ask Joanna Rogers to come in.

After the case is presented, the selected students are accompanied to the simulation room. 

While the case is developing, there are two key moments to which you should pay special attention: 

(a)   The students perform the blood sugar check-up (they can check the patient’s own records or decide to perform a blood sugar test)

(b)   The patient exposes her family conflict regarding the usage of technology for health monitoring and her willingness to stop following the recommendations

 

The students will have to communicate empathetically with the patient and be able to calm her down whenever she reacts anxiously. They will also have to communicate with each other effectively and without the patient noticing that there are things that they don’t know. You will need to pre-define the maximum duration of the case and find a realistic way to stop the case in the event that the students are not able to solve it (see above).

 

Step 3. Debriefing. In the debriefing phase, the students that were in the simulation room get back to the debriefing room with their peers and facilitator(s)/teacher(s). This is a moment for common reflection in which performing students offer an internal point of view of the simulation and observing students offer an external point of view of what happened and what could have been done differently. Therefore, it will probably be the phase that lasts the most. Topics that should be addressed are: 

(a)   emotions appeared during the case

(b)  investigation of the reasons that have led to the decision-making: whether, why and how performing students asked for help to other professionals;  how they redirected the patient; how did they manage the patient’s emotions; how did they get to negotiate with the patient.

(c ) transfer of learning to professional reality

 

After the activity

After the debriefing, it’s time for evaluation. Below, you can find a rubric to evaluate their socioemotional and interpersonal skills (both of students that performed in the simulation and those who observed it). You can also give it to them for self-evaluation in order to stimulate self-reflection.

 

Role of teacher(s)

The teacher(s) will facilitate the pre-briefing and debriefing activity. In both parts of the activity, an emotionally-safe space should be guaranteed. They will not get into the simulation room unless they play a role in which they make the simulation end realistically (e.g., the unit coordinator gets into the room for a check-in with the patient and offers to solve the situation).

Following the recommendations made by studies in simulation methodology, it is preferable to have two teachers in this type of simulation. One of them, the “instructor” and who will have accomplished a specific training in simulation methodology, will take the role of moderating and facilitating the session and debriefing, while the other, an expert in the content of the cases, will handle content clarification and questions.

Evaluation tool

Transversal skills are difficult to evaluate, particularly among big groups of students. Therefore, in this section we propose a tool for students to self-assess the development of these skills. The tool is divided into three dimensions: suitability of the learning activity, level of achievement of learning outcomes, and transferability to professional settings. You can adapt the dimensions and/or indicators that you use according to your teaching-learning context and needs. 

 

Evaluation tool to self-assess the development of skills during the activity

For each of the following statements, select the best answer on a scale from 1 to 4, where 1 means “Not at all” and 4 indicates “Yes, totally”. N/A means “not applicable”.

	1	2	3	4	N/A
DIMENSION 1. Suitability of the learning activity
I found this learning activity adequate in terms of time
I found this learning activity adequate in terms of resources (material resources, physical space, etc.)
I found this learning activity adequate in terms of content
I found this learning activity engaging
I found this learning activity challenging
I found this learning activity disruptive in comparison with other learning methodologies
I found this learning activity useful to learn [add the subject]
I found this learning activity useful to retain knowledge
This learning activity motivated me to deepen my knowledge of [add subject or hard skill]
This learning activity allowed me to feel emotions that would be rather difficult to experience with other learning methodologies
I would recommend this learning activity to others
DIMENSION 2. Level of achievement of learning outcomes
This learning activity helped me to improve…
…my ability to [add a row for each learning outcome of the activity that you performed, both related to hard and transversal skills]
DIMENSION 3. Transferability to professional settings
After this learning activity…
…I will be better able to apply what I learned to my reality (everyday life, classroom, professional life)
…I feel more capable to perform in a professional setting
…I feel I can make better choices regarding professional situations
…I feel more prepared and self-confident to address professional situations
OPEN QUESTION – Use this space to explain whatever you think is remarkable from the learning activity, including strengths, weaknesses, improvements, potential uses, feelings or dilemmas you encountered during the activity.

 

Download evaluation tool in pdf here.