2.3.1 Design policy of IR
There are many things to consider when practicing CEC: which parts of CEC to simulate in a CEC role-play—i.e., what learners will experience and learn—will depend on the readiness of the learners and the goals set for the course [16, 7]. It will also depend on the philosophical position of the CEC, such as how it is positioned as an activity. We designed IR as follows.
The IR is not designed for beginners, but as a practical and effective exercise for experienced professionals who may be in the clinical setting in the future.
We designed the IR role-play with the intention of having the participants experience and learn the following points among the many features and cautions of CEC.
(a) Importance of Narrative
One of the most important aspects of CEC practice is to be aware of the narratives of each person involved, to understand the ethical dilemmas in a case as narrative conflicts, and to seek to resolve them [17].
(b) Fragmentation of information
In reality, when we try to understand narratives, we do not have all the information available to us at the outset, which makes it impossible to have a bird’s eye view of each person’s situation. Thus, consultants are required to infer and grasp the overall picture from the fragmented information obtained [18].
(c) Information Fluctuations
The information accumulated to understand the narratives of the people involved will also vary depending on the method and timing of the intervention. The consultant is also a member of the stakeholders when they participate in the project.
(d) Importance of Communication
The CEC is an entirely communicative activity. There are a variety of things to focus on in each of the following areas: communication with the client, communication with stakeholders, and communication within the consultant team [19].
The above points can only be meaningfully experienced in a realistic and immersive environment. Therefore, in this study, we have also worked to ensure that fidelity is high in terms of physical and environmental fidelity, patient and stakeholder fidelity, and learner psychological fidelity.
Implementation of IR
We conducted the immersive role-plays (IR) using the following procedure. Participants were limited to approximately 15 people per training session, who had received prior training in the theory and skills of CEC. They were divided into three groups (four to five participants per group), according to their work experience, and were asked to participate in the IR as a team. Each group was provided with a different IR scenario, and the other groups who were not conducting a simulated consultation were allowed to observe as spectators.
The role-play scenario began with a consultant receiving a request, during which, the participants as consultants, met with relevant parties and gathered information. After the scenario was completed, it was reviewed, during which the participants organized and evaluated the information, analyzed the problem, and summarized the recommendations. After the review, the role-play ended with the recommendation being communicated to the client.
There was about 30 minutes of pre-briefing for the role-play, 60 minutes for the scenario progression, 60 for review, and 60 for observation of other groups. Finally, the overall debriefing took about 150 minutes, making the overall program about 6 hours long.
Preparation, Stage, and Staff of IR
The IR was held in a studio usually used for filming movies and TV dramas, and the stage was composed of a nurses’ station, lounge, examination room, and hospital room, each with a simulated patient, doctor, nurse, etc. (hereinafter referred to as “performers”). The stage was divided into sections, in which various scenarios were performed simultaneously and parallelly. ( Fig. 1)
Among the performers, trained actors were assigned to roles that played an important role in the scenario, such as the client, the patient, and the doctor. Although a script for the scenario was provided, the actors were instructed to be flexible in their communication with the learners playing the consultants. Rehearsals began about a month ago.
Progression of IR
Learners in the consultant’s role first received a phone call from the performer playing the client role and are given an overview of the case. Then, working together in a group, they (1) gathered information by meeting the people involved in the five stages, (2) thereafter, they used these information as clues to understand the narratives of each person involved, (3) then, they had to identify the ethical dilemma in the given scenario, and (4) seek ways to resolve or eliminate it. (5) Finally, the process was completed by communicating the answers to the client.
All IR proceedings were controlled by time, and the performers followed a predetermined table of actions (Table 3). After the IR started with a phone call from the client, events defined in the scenario occurred somewhere on the stage according to time; and after a certain amount of time, the final process of the IR: the event of providing a response to the client occurred. The structure of the IR progression was such that the learner playing the role of consultant could not know about all the events that occurred in the scenario, nor could they fully grasp the changes in the feelings of the people involved. Three IR scenarios were prepared, all of which took about one hour to complete.
Table 3
Table of actions of the main performers in Scenario 1 (Excerpts from some of the characters)
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The patient
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The patient’s partner
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The attending physician
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Time
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Major Events
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Contents
/Scripted part
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Contents
/Scripted part
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Contents
/Scripted part
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8:40
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Consulting Request
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8:45
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Move
to the stage
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8:50
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8:52
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Declaration
of Refusal
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Hospital Room B
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Conversation with doctor
Refusal of treatment
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Hospital Room B
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Doctor’s rounds
Conversation with the Patient
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8:50
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8:52
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Come to the hospital and go to husband’s hospital room.
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8:55
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8:57
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Patient’s roughness
Wife’s exhaustion
Nurses’ exhaustion
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Hospital Room B
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Refusing Care from Nurses
Awkward silence
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Hospital Room B
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Harassing interactions between husband and nurse
Awkward silence
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Nr.St
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Script
[Ph Action 1].
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9:00
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9:02
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Apology to medical staff
Wife exhaustion
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Hospital Room B
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To his wife, “Leave me alone.”
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Nr.St
lounge
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Leaves the HR and apologizes to the nurse at Nr. St.
Moved to the lounge alone.
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9:00
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9:02
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The head nurse and the attending physician
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Nr.St
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Conversation with the head nurse
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9:03
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9:05
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Differences in policies between doctors and nurses
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examination room
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Conversation with the head nurse
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9:05
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9:10
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Hospital Room B
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Script
[patient Action 1].
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lounge
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Script
[wife Action 1].
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examination room
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Script
[Ph Action 2].
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9:15
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9:17
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Concerns about medical errors
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Hospital Room B
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lounge
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Conversation with the physician
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Nr.St
lounge
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Found patient’s wife in the lounge, conversation
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9:15
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9:20
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Patient’s true feelings,
nurse’s change of heart
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Conversation with the head nurse
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9:18
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9:22
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The head nurse and the patient’s partner
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Hospital Room B
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Script
[patient Action 2].
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lounge
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Conversation with the head nurse
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Script
[Ph Action 3].
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9:25
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9:30
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Script
[patient Action 3].
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Script
[wife Action 2].
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9:40
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9:42
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Physician’s hesitation
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Hospital Room B
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Script
[patient Action 4].
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lounge
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Script
[wife Action 3].
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examination room
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Conversation with the nurse
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Hospital Room B
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lounge
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Script
[wife Action 4].
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examination room
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Script
[Ph Action 4].
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9:40
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9:42
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The Dilemma of Doctors and
Nurses
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Hospital Room B
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Script
[patient Action ].
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lounge
Hospital Room B
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Script
[wife Action 5]
Return to HRB
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examination room
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Conversation with the nurse
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9:45
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9:50
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Briefing sessions, statement of refusal of treatment by the patient
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HRB
examination room
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Move to doctor’s office
Briefing session begins
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HRB
examination room
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Move to doctor’s office
Briefing session begins
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examination room
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Briefing session begins
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9:52
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9:54
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The head nurse and the attending physician
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examination room
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Return to Hospital Room B
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examination room
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Return to Hospital Room B
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examination room
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Conversation with the head nurse
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10:00
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10:02
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examination room
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Call a Consultant
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There were 11 performers in Scenario 1, but the five people most involved with the CEC consultant were the patient, the patient’s partner, the attending physician, the nurse, and the head nurse (the consultant client). Detailed action charts were created for the above-mentioned five persons, out of which three are described here. The performers were experienced actors and a seminar staff (actual MDs and Ns) who had been training for several months.
MD: medical doctor
N: nurse
Nr.St: nurse’s station
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Features of IR
The researchers arranged for a studio, stage props, and actors to achieve a high fidelity regarding the environment, the patients, and other people involved. This was intended to increase immersion and the psychological fidelity of the learner. However, IR encompasses much more than that. One of the crucial features of IR was that the scenarios ran simultaneously and parallelly in five different stages. This had several advantages. First, in a real CEC scenario, it is impossible to obtain all the information at once, thus, making it necessary to understand the whole picture with limited information. The IR helps to mitigate difficulties like the inability (difficulty) to obtain information parallelly, can be used to train the inference “to grasp the whole picture from fragments,” which is indispensable in real consultation scenarios. Furthermore, because IR involves simultaneous and parallel scenarios, the participants are required to work actively and efficiently together as a team. Additionally, because the situation changes with the learner’s intervention, the learner must become part of the story and carefully intervene with the people involved. Thus, IR participants are encouraged to participate more immersively in the role-play as “one of the people involved” because of this dynamic mechanism of scenario development.
Evaluation of IR
In the IR, learners playing the role of consultants were evaluated by scorers on how well they performed their tasks. Scorers were placed at various locations on the stage. Performers also participated in the evaluation as commentators.
The evaluation was divided into individual and group evaluation items. The individual evaluation items were divided into four items for communication skills and two for commitment. The group evaluation items included three items that questioned the level of achievement in understanding medical facts, understanding the narratives of the people involved, and the effectiveness of problem-solving, including an item that questioned about collaboration within the team. All 10 items were rated on a 3-point scale, after which an overall rating (3-point scale) was determined. Evaluation sheets and performer comments were collected for each scenario, and an evaluation meeting was held after the completion of all scenarios.
Scenarios of IR
The following three scenarios were created by us as scenarios of IR, which were based on the theme of refusal of treatment. There are two main reasons why we created three scenarios on the theme of refusal of treatment. The first is because treatment refusal is often seen in Japanese clinical practice (against the background of Japanese cultural circumstances that differ from Western self-determination centrism) [20, 21]. Second, closely related to the first, is to contribute to the learner’s future problem-solving methods in the casuistic approach. In the casuistry, cases are accumulated, and for difficult cases, solutions are sought by comparison and analogy with other cases that have been resolved [22]. The accumulation of ethical considerations of similar cases of refusal of treatment will be a great asset for future learners.
Although all of the scenarios focus on the theme of refusal of treatment, the background and reasons for the refusal are very different, and in all scenarios, the learner is required to understand the narratives of the people involved and to resolve and resolve the conflicts. (Table 4)
Table 4
Scenario 1: Refusal of treatment stemming from being mentally trapped
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Time span: approximately 1 hour
Client: Head Nurse
This case involved consultation on how to deal with a 35-year-old male patient on dialysis due to diabetic nephropathy. The patient was hospitalized for a shunt reconstruction, but he became depressed and mentally trapped by his situation and started refusing to undergo catheter dialysis. Moreover, he was also causing problems by verbally abusing his wife and nurses.
The assignment of the consultation was to determine whether it is ethical to recommend discharging the patient from the hospital if he refuses to undergo shunt revision surgery.
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Scenario 2: Refusal of treatment for religious reasons
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Time span: approximately 1 hour
Client: Nurse in-charge
This case was a consultation regarding the treatment of a 40-year-old female patient admitted to the cardiology department for pulmonary hypertension. The patient needs a percutaneous cardiopulmonary support system (PCPS), but she refuses it for religious reasons. However, the attending physician does not care about the patient’s wishes and is trying to obtain Informed Consent from the family to proceed with PCPS because the patient is also being treated for schizophrenia.
The details of consultation was about what steps to take to be there for the patient.
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Scenario 3: Refusal of standard treatment stemming from an attitude of avoiding self-determination
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Time span: approximately 1 hour
Client: attending physician (Gastroesophageal Surgery)
This case was a consultation on how to deal with a 70-year-old female patient who is hospitalized for stomach cancer. The patient has started to avoid making decisions on her own after her husband’s suicide, and has refused the standard treatment proposed by her doctor for her stomach cancer, following the words of her eldest son who recommends non-standard treatment. The patient’s only stated wish is that she does not want to be transferred to a different hospital.
The assignment of consultation was how to deal with the patient’s reluctance to be transferred to a different hospital.
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