Utilizing Simulated Caregiver Scenarios to Cultivate Caregiver Perspectives and Empathy among Pharmacy Students within Ambulatory Care

Abstract

Objective: To cultivate caregiver perspectives and empathy through computer-based simulations in the ambulatory care setting. Methods: A total of 46 third-year students were enrolled in the 2-week ambulatory care elective at the University of Florida College of Pharmacy. Students were assigned 5 computer-based simulated scenarios, each created to encompass elements regarding social determinants of health from a caregiver perspective. After each scenario, students were required to complete a post scenario assessment where students were tasked with reporting their emotional response by providing 3 adjectives upon completion. After completing all caregiver scenarios, students completed a postsimulation reflection connecting their experience with caring for their future ambulatory care patients. Both individual and final reflections were analyzed and assigned to the themes of emotional strife, compassion/understanding, self-reflection, resilience, and/or other to determine proportion of identified themes. Results: For the individual caregiver scenarios, the most identified theme was emotional strife amongst all scenarios (45%-68%). Regarding the final reflection, most of the theme identified were compassion/understanding (46%) followed by self-reflection (29%). Emotional strife was the least identified theme in the final reflection (7%). Conclusion: After students completed all the caregiver scenarios, students reported higher levels of compassion/understanding and self-reflection when compared with other identified themes. Through this computer-based simulation, students gained a better understanding and empathy toward the caregiver perspective when faced with common health care disparities in an ambulatory care patient population.

Introduction

Patient caregivers are often overlooked despite the understanding of how important their role is to the patient.^1,2 One potential strategy to help health care professionals better understand the value and role of caregivers earlier in their training is to embed educational interventions in their degree programs. The use of simulations and patient cases in understanding the emotional state of a patient or caregiver may be a way to help fill this overlooked aspect of patient care. Parker et al ³ conducted a simulation with pharmacy students enrolled in an elective diabetes course immersing themselves as a patient attempting to manage diabetes. At the completion of the short 3-day simulation, the students identified themselves as gaining more empathy for the patient themselves. In another study in which pharmacy students were also enrolled in a diabetes elective course, a 3-week simulation was conducted to simulate both the patient and the provider roles in diabetes management. ⁴ At the completion of this simulation the authors found a significant improvement in empathy for patients with diabetes. Along with these results, 2 reviews have been published reviewing the use of simulations to develop empathy for patents, both of which conclude the efficacy of this approach.^5,6

Despite the efficacy seen in developing empathy for the patient using simulations, the literature reviewing the use of computer-based simulations for caregivers is lacking. Hur et al ¹ conducted a systematic review involving caregivers within the team-based approach of patient care and the use of simulations to educate nursing students on caregivers. However, this review found that these simulations were focused mainly on increasing caregiver education and not the emotional aspects of the caregiver and treating them as an adjunctive patient. Another study conducted by Chaker et al ⁷ showcases how the primary focus of caregiver studies is on the abilities of caregivers to manage their loved ones with a specific disease state or medical issue and not the students’ understanding or development of empathy toward caregivers themselves. There is currently a lack of medical literature on the value of computer-based simulations and their ability to educate students and connect them on an emotional level with caregivers. The purpose of this simulation was to increase awareness and empathy for caregivers by immersing students in the challenges of health care barriers in an ambulatory care setting. ⁸

Methods

Course Overview and Learning Objectives

Our college’s curriculum was updated to move beyond traditional-based learning to incorporate innovative teaching methods such as team-based learning and active learning sessions, following self-directed lecture viewing. Additionally, our curriculum is organized into blocks to group related content across different courses.

The first year focuses on building a strong foundational knowledge base, covering topics such as pathophysiology, medicinal chemistry, drug delivery systems, pharmacokinetics and pharmacodynamics, evidence-based practice, population health and law and ethics.

In the second and third year, the curriculum is divided into blocks that focus on a specific organ system. For instance, Block 7 concentrations on the cardiovascular and pulmonary systems, where students apply principles of pathophysiology, medicinal chemistry, pharmacology, pharmacotherapy, patient assessment and more to treat related disorders. This block spans 7 weeks.

At the end of each semester, second and third-year students can choose electives that align with their interests and deepen their expertise in various specialties. The “Ambulatory Care” elective is a 2-week course where third-year pharmacy students enhance their clinical knowledge, skills, and understanding toward becoming proficient practitioners in the ambulatory care setting. Emphasis is given to various computer-based simulations throughout the elective course. To achieve the learning objective “Demonstrate understanding of the role and challenges a patient caregiver has in comanaging patient medical needs,” 5 caregiver simulated scenarios were developed and implemented within the course.

Development of Caregiver Patient Scenarios

The simulated scenarios were computer-based, and a link to access them was embedded within the Canvas course. They were developed using Twine, an open-source tool designed for creating interactive, nonlinear stories. Twine requires no programming experience, making it accessible for educators and designers looking to build digital branching narratives. With a simple interface, users can create passages of text and link them together to form decision trees or story paths.

Using Twine, we created a series of branching, “choose your own adventure”-style scenarios. Each scenario consisted of a complex network of interconnected story nodes, with each node representing a key event or decision point in the caregiver’s journey. This structure enabled us to build a dynamic virtual simulation where learners could explore multiple pathways based on the choices they made, resulting in a more engaging and personalized learning experience.

Learners began the simulation with a narrative introduction establishing their role as a caregiver and providing essential context about the patient. This grounding information placed learners directly into the caregiver’s perspective. As the simulation progressed, learners encountered various unfolding events, each requiring them to make critical decisions. Woven throughout the scenarios were influences of social determinants of health, such as access to health care, financial stability, and social support systems. When selecting a response, they were guided to a corresponding outcome, leading to new challenges and decisions. Each path branched into different directions, ensuring that every decision carried consequences and shaped the ongoing narrative.

The simulation was carefully designed to reflect real-world caregiving challenges, drawing on the faculty’s extensive experiences as practicing ambulatory care pharmacist who serve diverse patient populations. Scenarios were framed in the first person, fostering empathy by making learners consider the caregiver’s emotional and practical struggles. This approach helped create a meaningful learning experience that encouraged thoughtful decision-making and a deeper understanding of the complexities caregivers navigate daily.

Students accessed the virtual simulations through Canvas learning management system, where they could complete them independently at their own pace. Each simulation took approximately 10 minutes to finish. Upon completion, students received a number code generated by the simulation, which they entered a Canvas assignment to verify completion. They also answered reflection questions designed to deepen their understanding of the experience and encourage critical thinking about the caregiving challenges they encountered. To support exploration and learning, the simulations remained accessible, allowing students to revisit and try different decision pathways. Scenarios were released one at a time over 5 consecutive days, ensuring a structured yet flexible learning experience that built progressively on the complexities of caregiving and social determinants of health.

Scenario #1—A Partner’s Plight

In the first scenario, learners stepped into the role of a female caregiver to her same-sex partner, a 76-year-old woman managing diabetes. At the partner’s clinic appointment, the learner encounters initial hurdles, feeling unrecognized as a caregiver despite their long history together. The scenario prompts learners to navigate advocating for themselves and the patient’s care needs, highlighting the emotional toll and complexities of being a caregiver in a same-sex relationship. These issues underscore the challenges faced by LGBTQ+ individuals, emphasizing the need for self-advocacy and addressing social determinants of health including health care disparities and access to quality care.

Scenario #2—A Father’s Journey

The second scenario focused on a single father caring for his son and his diagnosis of diabetes and autism. The learner is faced with decisions on managing the son’s day-to-day routines (school, extracurriculars, disease state exacerbations) all while managing their own responsibilities as a caregiver. The scenario addresses issues of health care access and quality in schools, emphasizing the importance of diabetes education and training for educators and staff to recognize and respond effectively to diabetic emergencies.

Scenario #3—A Daughter’s Balancing Act

In the third scenario, learners take on the persona of a 33-year-old mother as the sole caregiver of her 3 young children and father. Learners are faced with a health crisis pertaining to the father and are left to make decisions as to how to balance responsibilities toward both him and the children. This scenario highlights the importance of social and community support networks and neighborhood environments, as the caregiver relies heavily on her neighbors for assistance during critical moments.

Scenario #4—A Student’s Dilemma

This scenario has the learners simulate a financially struggling college student and the responsibility of caring for their grandfather who is afflicted with dementia and diabetes. The learner is forced to manage multiple responsibilities such as his academics and providing proper care for his grandfather, all while experiencing financial strain. In the context of social determinants of health, multiple domains come into play including economic stability, social and community context, neighborhood and built environment, and education access and quality.

Scenario #5—New Diagnosis Difficulty

This scenario involves a caregiver who is initially stepping in to assist in the care of their mother who was recently diagnosed with a blood clot and given a 30-day supply of brand name only anticoagulant upon hospital discharge. The learner, acting as the caregiver, must quickly adapt to the intricacies of navigating barriers to care including, but not limited to, establishing a provider, medication accessibility, and transportation. The scenario underscores how social determinants of health significantly influence patient care and well-being. It touches on domains such as economic stability, social and community context, neighborhood and built environment, and health care access and quality, emphasizing the interconnected factors that impact health outcomes.

Collected Data

Two different types of qualitative data were collected from the enrolled students. After the completion of each caregiver patient scenario students were asked to complete a graded quiz. These quizzes were graded based on completion, ensuring that the students followed the directions and answered the following question:

1. List 3 adjectives that describe how you are feeling after going through this patient caregiver scenario.

These adjectives were compiled into a spreadsheet and reviewed anonymously and independently by 4 investigators. These investigators were part of the elective course. Investigators placed each adjective into 1 of 5 themes determined by the investigators, which emerged from the students’ responses to encompass most of the of adjectives used: Emotional strife, compassion/understanding, self-reflection, resilience, and other. The most selected theme was designated and for any ties, a discussion was had to select the theme. At the end of the course students were asked to complete a graded final reflection limited to a 500-word essay or 4-minute audio/video file with the following prompts to connect their experiences with how they will care for their future patients:

1. How has your perspective changed for patients and their caregivers on multiple medications/disease states and with possible compliance issues?

2. After completing this course, what do you believe is the role of a pharmacist and caregiver in managing not only therapies but also assisting to relieve potential barriers patients and their caregivers may face?

3. In what ways did this course develop your clinical knowledge and empathy skills toward assisting complex patients and their caregivers?

The final reflections were graded based on completion, ensuring that the students followed the directions and answered the above prompts. The final reflections were de-identified and searched for key terms indicating that the students discussed the caregiver patient scenarios in their reflection. The final reflections were included in the study if they had one of the following search terms: “caregiver simulation,” “caregiver scenario,” “caregiver situation,” and “caregiver patient scenarios.” These search terms were selected, as not all students were required to specifically write about the caregiver scenarios. Reflections that did not include these search terms were excluded from the study. Investigators then reviewed these reflections and placed each into the 5 themes. Given the variability of a free response format for this reflection, investigators were given the opportunity to select more than one theme if it fit the reflection. Investigators met to discuss any discrepancies for both data sets. This study was granted IRB exemption prior to conducting the research.

Data Analysis

Data were analyzed using descriptive statistics.

Results

A total of 46 third year pharmacy students were enrolled in the course. All 46 students completed the caregiver patient scenarios and the final reflection. For each caregiver scenario, each investigator reviewed 138 adjectives (3 adjectives/student) and assigned themes. A total of 552 adjectives were assigned a theme. The breakdown between caregiver patient scenarios was similar, with emotional strife as the most identified theme between 45% and 68% of the time. The remaining themes varied between each scenario and a breakdown of each caregiver patient scenario can be found in Figure 1.

Figure 1.

Caregiver scenario reflections assigned themes (n = 552).

For the final reflection, 5 student reflections were excluded due to not meeting inclusion criteria (missing a key search term). Forty-one reflections were reviewed, and each theme could potentially be selected one time by each investigator for a total of 4 times per reflection. A total of 332 themes were assigned. The most identified theme was compassion/understanding at 46%, followed by self-reflection and resilience, 29% and 19% respectively, with emotional strife at 7% (Figure 2).

Figure 2.

Final course reflections assigned themes (n = 332).

Discussion

Through computer-based simulations, students were able to experience the role of a caregiver within the ambulatory care setting. Regarding the individual scenarios, students gained a better understanding of the emotional strife that caregivers face as this was the majority theme identified. By the completion of all scenarios, the more positive themes of compassion/understanding and self-reflection surfaced. An unanticipated theme at the end of the computer-based simulation was resilience as 19% of students reported. This outcome not only speaks to empathy that students experienced upon completion of the scenarios but also emphasizes the role of reflection within health care as the practice of reflection has been shown to provide better insight into the development of critical thinking skills and attitudes when caring for patients in the medical field.^{9 -11}

This study is not without its limitations. The absence of a baseline assessment of the students’ perceptions of caregivers as there is no ability to determine if the incorporation of the caregiver scenarios influenced the themes identified within the final reflection. In addition, the results are limited, as the elective course had only a small number of students exposed to these scenarios. Finally, it is worth noting that implicit bias may have presented itself as a confounding factor that influenced the student decisions in showing empathy to certain caregiver scenarios.

This experience solely focused on the caregiver experience without incorporation of this perspective from a clinical decision standpoint. One could consider the element of clinical decision-making toward simulated patients and caregivers tailored to the role of the pharmacist and actionable items pharmacists can take to relieve the emotional burdens of caregivers. To accomplish this, students could make a clinical decision at face value when presented with a patient and then conduct a caregiver experience to see how it would affect their clinical decision. This would also be helpful in determining if there is a correlation between simulated caregiver experiences and adherence to pharmacological and nonpharmacological treatments. In tandem, it would also be valuable to assess if there are differences in clinical decisions made between student social classes and gender disparities. Further studies evaluating the clinical impact that the role caregivers have would greatly benefit the medical community.

Conclusion

These computer-based simulations enabled students to experience the emotional strife caregivers face when caring for their loved ones. The students enrolled in the course received a better understanding of the barriers to health care that ambulatory care patients face and the roles and responsibilities of their associated caregivers. By the end of the simulations, students reported an empathetic perspective of a caregiver, one of compassion/understanding, self-reflection, and resilience.