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COVID-19 has presented many challenges to all aspects of the medical environment, including teaching and learning.1 2 Following an almost complete cessation of face-to-face simulation teaching activities in Spring 2020 due to COVID-19, we adapted and turned to the use of creative solutions to teach clinical skills in a safe but effective learning environment.
Simulation training in psychiatry has traditionally focused on communication skills teaching and learning.3 4 Previous reports discussed the advantages of simulation as an alternative to role play for providing trainees with clinical experience in a safe learning environment with the potential for improved educational outcomes.5
We outline our experience of running a socially distanced simulation workshop for a multidisciplinary group of learners in psychiatry, combining a small number of in-person learners and a larger number attending synchronously and remotely using Zoom audiovisual technology.6
Galway University Hospitals (GUH) is a tertiary teaching hospital on the west coast of Ireland. It has an on-site simulation facility, the Irish Centre for Applied Patient Safety and Simulation. With the Department of Psychiatry at GUH, they have previously delivered a multidisciplinary simulation workshop on common psychiatric presentations.7 Psychiatry staff were keen to develop a follow-on workshop and to include participants from emergency medicine (EM).
Using a collaborative iterative approach, a workshop using simulated patients (SPs) focusing on diagnosis and management of rare but challenging psychiatric emergencies was developed: ‘SafePsych’. Three scenarios, informed by feedback from psychiatry trainees, were developed: managing a patient with neuroleptic malignant syndrome, a critically unwell patient with anorexia nervosa and a patient with psychosis, presenting following an alleged indictable offence.
Ethical approval was granted by the Saolta Clinical Research Ethics Committee (Ref CA2060). Psychiatry trainees, EM trainees and consultants were invited to attend via departmental email. Nursing staff of the Liaison Psychiatry team and the Acute Adult Mental Health Unit at GUH were also invited to attend.
SafePsych was developed and run in July 2020. A small number of learners attended in-person at the simulation facility in compliance with Government COVID-19 guidelines.8 The remainder of learners along with senior faculty members attended online via the Zoom platform. Following a prebrief, each simulated scenario lasted 15–10 min, allowing time for two trainees to participate in each scenario. Debriefing followed each scenario and included the participant learners, the SP, the confederates and senior EM and psychiatry staff. Following this, a brief update on current guidelines relevant to each scenario was provided.9 10 Consultant observers online provided feedback to learners and offered expert opinion and advice on management.
Participants completed a postworkshop feedback document, either online or in-person. This comprised of Likert scales assessing usefulness of learning to clinical practice and relevance of material presented and free-text responses. Themes included appreciation of realistic and relevant scenarios, an emphasis on learning not assessment and welcoming a worthwhile teaching experience delivered with psychological safety.
While over 90% of the participants enjoyed the workshop and agreed that it was useful in addressing their learning needs, there was a significant minority who found the experience of being observed by the larger number of participants anxiety-provoking.
This issue of trainees feeling intimidated by performing under pressure of a large audience has been noted elsewhere11 and is discussed in literature exploring the effects of psychological safety.12 Psychological safety describes people’s perceptions of the consequences of taking interpersonal risks in a particular context such as a workplace or training environment. Organisational research has identified psychological safety as a critical factor in understanding phenomena such as voice, teamwork, team learning and organisational learning.12 If this is not adequately considered, the resultant anxiety and stress will inhibit performance and learning. Participants actively involved in the scenarios gave feedback such as ‘it was nerve-wracking to consider the large number of peers and senior colleagues watching online’, ‘everyone watching’, ‘intimidating for the participants’. This unanticipated effect of using technology to improve accessibility needs consideration in the planning and recruitment stages.
All trainee and nursing respondents reported finding the workshop helpful and relevant to their clinical practice. Most felt it would inform their practice and welcomed the referenced guidelines.9 10 Respondents felt the aspect of joint learning with colleagues from medical, nursing and ED colleagues enhanced the relevance of the scenarios, adding to the fidelity of the learning experience.
The Zoom remote aspect was broadly welcomed in making this learning available and accessible to the wider audience, although perhaps our most significant finding was the unanticipated effect of that audience on the learner participants. This additional stressor and the impact of remote observers on the psychological safety of the in-person learners needs attention in planning future iterations of the workshop (figure 1). A smaller number of attendees and additional time spent in the prebrief ensuring introductions and clear understanding of roles and expectations may mitigate this effect.
Challenges encountered by the facilitators not only included remote participants being affected by connectivity issues but also the ability to manage the ‘live’ learners in the room while communicating effectively with the remote audience.
Delivery of this workshop to in-person attendees allowed for high-quality simulation-based experiential learning for these learners. The hybrid approach of combining the in-person and online participants allowed us to deliver a worthwhile teaching experience in a safe manner. The psychological safety of our learners is key in ensuring active participation and a supported learning experience. A key focus should be on underlining the formative nature of the process in order to minimise concerns regarding rating of performance.
Planning for the delivery of the session should include clear role allocations for the facilitator team. A key facilitator to manage the online audience and integrate this more effectively would add to the remote participant experience. The challenges of connectivity will remain, although we have significantly upskilled and are more adept at the smooth running of online platforms.
Our experience of this approach to simulation education suggests that a hybrid virtual simulation workshop is a feasible method of delivering high-quality teaching in complex areas of psychiatry.
Contributors All authors contributed to the planning, design and delivery of the workshop as described. EEM, KT and AD devised the scenarios taught in the workshop and EEM, DB and AD contributed to the writing of this letter. AD supervised all aspects of this project and was lead facilitator of the workshop.
Funding This workshop was funded by Spark Seed Funding as part of the Spark Innovation Programme led by the National Doctors and Training Planning (NDTP) Unit, Health Service Executive (HSE).
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.
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