Basically, two different concepts are conceivable for simulating ethics case consultations:
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Simulations in which the simulation staff is recruited from the group of participants (peer-to-peer simulation) and
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Simulations in which at least the key roles are taken on by professional simulation people (simulations with simulation people).
Peer-to-Peer Simulation (PtP-Simulation)
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In the PtP simulation, the participants in the simulation are recruited from the group to be trained (Peers). This is initially practical because the simulation staff is immediately available to the group to be trained and does not need to be organized additionally. This is by no means just an awkward solution: the PtP simulation combines the concept of simulation role play with elements of peer-to-peer teaching/peer learning, which Degn et al. (2023, p. 77 f.) According to it, it has numerous specific advantages – such as a reduction in fear of the simulation, an increase in the self-confidence of the person playing and an improvement in cooperative learning – compared to conventional approaches. The Peers are also an essential source of skills-building feedback as part of the simulation debriefing. You benefit as an observer with regard to the learning goals to be realized and also personally by switching from the participant perspective to the consulting perspective in the simulations. Here you can determine through your own experience how a certain performance affects the process and its participants, thus offering an additional perspective on the structures and processes. The effectiveness of PtP simulation has already been empirically proven (e.g. Dieckmann et al. 2008, p. 644). However, there are naturally limits to the productive implementation of background information in PtP simulations, as this requires acting skills that are not necessarily possessed by the Peers be brought along.
Simulation with simulation people (SP simulation)
SP simulations are role-playing games in which one or more roles are taken on by (amateur) actors. SP simulations are particularly suitable for training or teaching in areas in which practical activity is complex and the practical transfer of theoretical knowledge represents a particular didactic challenge. The implementation (“shows how”) of complex tasks, including their communicative, emotional and psychological challenges, can be trained very well through simulation training with simulation people (Lane and Rollnick 2007; May et al. 2009), so this form of training has a particular benefit here (Rosen 2013; Aebersold 2016). SP simulations are therefore part of the training standard in many areas of medical training (Motola et al. 2013; Peters et al. 2019), are traditionally used in particular for training communicative skills (Rosenbaum et al. 2004) and have also been suggested for use in medical ethics teaching (Tritrakarn et al. 2014; Souza and Vaswani 2020; Seifart et al. 2022).
In SP simulations, simulation persons take on individual key roles in a case scenario, such as a doctor or relatives. Simple, complementary roles can still be used by Peers be taken over. The simulation people are specifically trained in advance to portray these people as realistically as possible. You will receive a detailed role script and will be introduced to all the important aspects of the person you are portraying that are necessary to be able to slip into their “skin”. This includes, among other things, important biographical data or medical history, family or professional situation, your values and internal conflicts. This allows them to embody that person in a consistent way in different scenarios. Although the roles and background are predetermined, different dynamics can develop in the simulation through the interaction. Simulators can also modulate the events by emphasizing certain aspects as necessary in order to make the simulation role play more or less demanding. In addition, simulation participants receive feedback training in order to be able to give personalized feedback after the simulation, which addresses both the quality of the execution of the skill and also includes perception from the perspective of the person being played (cf. Hatala et al. 2014).
Since simulation people are trained specifically for use in a simulation, they are experts in the execution and implementation of roles. In addition, the training ensures that the goals set out in the role description are also specifically addressed through the simulation.
There are standards and instructions for SP simulations in medical training (Cleland et al. 2009; Motola et al. 2013; Peters and Thrien 2018, pp. 63–73). The same applies to medical ethics teaching in German-speaking countries (Seifart et al. 2022). However, SP simulations have so far only been used sporadically in the training of ethics consultants.
Comparative considerations
Both concepts have advantages and disadvantages, which are discussed below based on the criteria of requirements and feasibility, access hurdles, manageability and variability, reproducibility, realism and feedback quality.
Requirements and feasibility
Its main strength lies in the feasibility of the PtP simulation. If there is a suitable case presentation, appropriately developed role cards and a suitable briefing or debriefing concept that can be carried out by a competent person, no further conditions need to be met in order to realize a simulation and achieve the corresponding learning objectives. Such an approach saves time, personnel and therefore costs.
The weakness of SP simulations lies in the area of feasibility: In addition to much more detailed case scenarios, they require the availability of simulation people. The latter must also be trained by competent simulation trainers before they are used. This creates greater human, time and therefore financial effort. At the same time, the SP simulation is less flexible in terms of time, as the use of simulation people must be precisely planned in advance.
Access barriers
Experience shows that role-playing games are not always popular. Participation in a simulation often represents a certain hurdle for the people playing. There is empirical evidence that PtP role-playing games are less popular than SP simulations, at least among medical students (Herchenröther et al. 2021; Gilligan et al. 2020). The fact that the simulation persons are mostly unknown to all participants and there is no network of relationships can make access to the simulation easier for the participants, but can also represent a perceived greater hurdle because “foreign” people are involved.
Manageability and variability
Whether a PtP simulation works well depends primarily on the quality of the case scenario and the care of the briefing. The participants’ competencies to play a specific role in a simulated ethics case consultation and to react appropriately to the advisor’s interventions are naturally unevenly distributed, so that the course of the simulation will develop a more or less random dynamic of its own. This is not a fundamental problem, as random momentum can of course also be a challenge for the person advising in the simulation. However, this means that the controllability and, above all, the variability of the PtP simulation are rather limited. With Peers As simulation staff, it is rather difficult to emphasize a specific problem aspect within a given spectrum or to vary it in a second pass. Simulators, on the other hand, have the necessary skills to do exactly this in a subtle way. This allows the situation to be planned, controlled and repeated, so that the quality of the execution of the skills can be checked and, if necessary, learned repeatedly.
During the training of ethics consultants, the different phases of ethics case consultation could be separated from each other, simulated one after the other and even run through several times. It is also possible to vary the severity and challenges. This is also possible within the same case scenario. For example, a relative who is represented by a simulation person could be willing to agree in an initial simple simulation if they receive friendly information about the patient’s situation, for example to first practice and deepen procedures. In a more difficult variation of the same scenario, the same person might insist on his or her point of view, creating a greater communicative hurdle.
reproducibility
In a PtP simulation, the more or less random momentum of the simulation, similar to controllability and variability, leads to rather limited reproducibility. It cannot be assumed that the same case will always lead to similar courses and results in different groups. There is too much variation in the implementation and design of the barely conceived roles by the participants, who only have a few minutes to prepare for the simulation. This can lead to very different courses and also different recommendations. This is not a fundamental problem either, as this issue has no meaning for the person advising in the simulation. However, sometimes it may make sense from the trainer’s perspective to have a certain aspect worked on in the same way.
Simulation persons are trained to be able to stop conversations in order to obtain input from teachers or observers present, or to continue the case consultation in a new or different way on a point to be determined jointly by those involved. A simulation can be interrupted and run again using a different approach or question. This means you can find out directly what influence different interventions have. In training for ethics consultants, an example of a different approach could be to start the consultation specifically with the question of the medical indication or the patient’s wishes in order to determine the ethical problem. In repeating loops, simulation subjects can, for example, live out their values in an increasingly expressive way, so that the ethics advisors can practice and reflect on their required “neutral” role. These types of targeted didactic interventions also reinforce vicarious learning for those present and observing the simulation.
Realism
The realism of the case scenario is based on the thorough preparatory work of the person training. However, whether the simulation process based on this runs realistically depends on the performance of the simulation staff. This is an advantage of using SPs, which are trained to make the simulation as realistic as possible. If participants in a moderation seminar are used as role bearers, many of them have sufficient field competence (see: Seifart and Göbert in this issue) to take on different roles in a simulation setting. However, it still happens again and again that there are problems when implementing a role profile – for example, when employees of a professional group or a specific healthcare facility take on a role that is far removed from their real function and personality. In this respect, compromises may have to be made in terms of realism. In addition, not all participants have the same ability to put themselves in the role of a fictional person and portray it realistically. If necessary, a simulation can appear “wooden” or “flat”. Too much “staging” of individual role-play participants can also lead to aspects being overemphasized and the simulation taking on a grotesque or caricature character (Dieckmann et al. 2008, p. 646). It should also be taken into account that it is not uncommon for there to be relationships between participants, which can make the PtP role play more difficult, for example if people laugh about the dynamics during the course of the simulation or spontaneous meta-discourses arise. However, an appropriate briefing can often effectively address such problems.
Simulation people usually have no relationships with the person playing. This means that they can (repeatedly) play out their role neutrally and give targeted feedback as a “foreign person” on the respective task. Simulations with (unknown) simulation persons are more realistic, as the ethics consultants being trained are confronted with an unknown situation on the one hand, but also with unknown people, thus providing greater proximity to the expected requirements in practice. After the initial training of ethics consultants, the problem often arises in everyday life that the newly trained ethics consultants are afraid to carry out ethics case consultations because they find the complexity of such advice, which is often emotionally charged, too difficult and challenging. This is particularly true if a team is to be formed and does not have any experienced ethics consultants. An SP simulation can prepare you even better for this than a PtP simulation, as it allows you to experience an unknown situation with “strangers” in a protected setting.
Feedback quality
Die Peers in PtP simulations are usually not trained to provide feedback. It is therefore necessary to explain some feedback rules at the beginning of the debriefing. However, this cannot always ensure that optimal feedback is provided. Not every feedback is comprehensible in terms of content or appropriate in form and therefore useful for the addressee. If the debriefing and the feedback it contains are understood as a joint critical reflection process and not as a one-sided identification of competence deficits, a joint Learning space can be designed, which in turn can be advantageous in terms of group dynamics.
Simulation participants receive feedback training in order to give personalized feedback after the simulation, which can address both the quality of the execution of the skill and perception from the perspective of the person being played (cf. Hatala et al. 2014). This opportunity is particularly valuable because a structured and targeted reflection of the experience by the other person enriches the trainees’ wealth of experience and thus prepares them well for later practical requirements.
