Simulation Learning to Train Healthcare Students in Person-Centered Dementia Care

Abstract

In coming decades, healthcare providers will treat a greater number of individuals living with Alzheimer’s Disease and related dementias than ever. Simulation-based learning provides experiential learning opportunities to enhance clinical training, but little is known about how dementia simulation training improves understanding of dementia or how it changes in participants’ ability to deliver high quality healthcare to individuals living with dementia. In this study, we examine how a simulation training program may prepare healthcare trainees to treat individuals living with dementia. We conducted 8 in-depth, one-on-one interviews with healthcare trainees who participated in the Virtual Dementia Tour (VDT) program and faculty who added VDT to their curricula, and also examined 20 reflection papers from students following participation in VDT. A thematic analysis of qualitative data led us to three themes: 1) dementia simulation complements and enhances traditional teaching methods, 2) dementia simulation helps students to understand the experiences of people living with dementia, and 3) experiential learning inspired students to reflect on actions they would take as clinicians and leaders to support individuals living with dementia and their families. Based on these findings, we propose a modified transformative learning process for dementia simulation training with healthcare students.

Introduction

In decades to come, healthcare providers will treat a greater number of individuals living with Alzheimer’s Disease and related dementias (ADRD) than ever. The growth of the older adult population—the population at the highest risk of experiencing ADRD— and lack of a cure means that patients are more likely to arrive in healthcare settings with ADRD (Alzheimer’sAssociation, 2019). Persons living with ADRD have multiple healthcare needs which necessitate practice modifications, such as the inability to remember care instructions, limited communication skills, potential impairment of decision-making capacity, and presence of behavioral symptoms. Practitioners across specialties and practice scopes need to understand how to meet the healthcare needs of individuals living with dementia. In this study, we examine how a simulation-based training program developed by Second Wind Dreams called the Virtual Dementia Tour (VDT) may prepare healthcare trainees to treat individuals living with dementia.

The Need for Training in Dementia Care Among Healthcare providers

Prevention and Management of Behavioral Symptoms of Dementia

Healthcare settings are underequipped to meet the needs of those living with dementia (LaMantia et al., 2016). This is evident with regards to the treatment of behavioral and psychological symptoms of dementia (BPSD) that affect most individuals living with ADRD. BPSD include changes in emotions, perceptions, and functioning that contribute to unusual, disturbing, and potentially dangerous behaviors (e.g., verbal aggression, wandering) (Cerejeira, Lagarto, & Mukaetova-Ladinska, 2012). Healthcare students describe negative feelings towards people living with dementia who exhibit BPSD and lack of confidence when managing challenging BPSD behaviors (Kimzey, Mastel-Smith, & Alfred, 2016).

BPSD may be aggravated during healthcare encounters. Although the precise etiology of BPSD is unknown, many consider behavioral symptoms to be a distress response to environmental stimuli or expression of unmet needs (Cohen-Mansfield, 2001; Smith, Gerdner, Hall, & Buckwalter, 2004). Stays in healthcare settings including hospitals, rehabilitation centers, and skilled nursing facilities may aggravate behavioral symptoms, such as through the presence of loud alarms and other disruptive sounds that are regular features of hospital and long-term care settings (Garre-Olmo et al., 2012).

The management of behavioral symptoms in healthcare settings is also cause for concern. Prompt management of behavioral symptoms can be important in healthcare settings to preserve the safety of the person living with dementia, other patients, and providers. Non-pharmacological interventions are preferred as a first-line treatment for BPSD, although their implementation is time-consuming and requires a particular skill set (Gitlin, Kales, & Lyketsos, 2012). Non-pharmacological interventions can include environmental adaptations and problem-solving skills; their application has a medium-size effect on the reduction of BPSD overall (Brodaty & Arasaratnam, 2012). Investment in provider training to administer non-pharmacological interventions is an effective way to reduce behavioral symptoms and to lower the use of antipsychotic medications in skilled nursing settings (Roberts, Smith, & Bowblis, 2019). Among hospital staff, better understanding of patient behaviors resulted in more problem-solving behaviors and fewer negative responses to BPSD (Handley, Bunn, & Goodman, 2017).

Provision of Person-Centered Care

Beyond the prevention and appropriate treatment of behavioral symptoms, healthcare providers are urged to administer person-centered care to persons living with dementia. Person-centered dementia care is described as care based on the needs of individuals that are learned from interpersonal relationships with that person (Fazio, Pace, Flinner, & Kallmyer, 2018). Calls for person-centered dementia care are a response to biomedicalized or depersonalized approaches to care, which emphasize disease processes at the cost of social recognition of the individual experiencing ADRD (Fazio et al., 2018; Lyman, 1989). To combat depersonalization, the Alzheimer’s Association recently identified practice recommendations to promote person-centered care to people with dementia, such as: getting to know the person, recognizing and accepting the person’s reality, and nurturing authentic relationships (Fazio et al., 2018). Individuals living with dementia themselves describe wanting providers to get to know them as individuals, to listen to them, and to be patient (Alzheimer’sAssociation, 2018).

Training Programs to Prepare Dementia-Capable Healthcare Providers

Healthcare training organizations and educational institutions are challenged to prepare students to provide effective, safe, and person-centered care to individuals living with dementia. Several programs have been developed and employ a combination of learning activities, including: analysis of case studies, videos-based learning, book clubs, and clinical experiences with people living with dementia (Kimzey et al., 2016; Lorio, Gore, Warthen, Housley, & Burgess, 2017; Mastel-Smith, Kimzey, & He, 2018). Findings from these interventions are generally positive; programs administered to physical therapy and nursing students increased participants’ confidence when delivering care to someone living with dementia, increased knowledge of the disease, and improved attitudes about dementia (Lorio et al., 2017; Mastel-Smith et al., 2018). However, a drawback of existing multi-component programs is their lengthy administration period (10 to 12 hours), thus making it difficult to incorporate these into clinical training curricula.

Besides multi-component programs, clinical experience and computer-based modules alone have also been evaluated for their ability to prepare healthcare students to work with patient populations living with dementia. One program used a 7-part CD-ROM course to deliver lessons to licensed practical nurse students on topics including communicating with a person who lives with dementia, managing behaviors, environmental considerations and more (Ruiz, Smith, van Zuilen, Williams, & Mintzer, 2008). Participation in the program was associated with improved knowledge of dementia, self-efficacy, and increased desire to work with individuals living with dementia in bivariate analyses. However, benefits from computer-based programs may be limited. Compared to students who underwent a clinic experience working with people living with dementia, students who completed an online training plus clinical experience with cognitively intact patients had fewer gains in knowledge and attitudes about dementia (Kimzey et al., 2016). These findings suggest that training that extends beyond knowledge acquisition and into higher levels of learning (e.g., application, analysis) is called for to prepare healthcare trainees (Adams, 2015).

Simulation and Transformative Learning

Simulation learning is a viable approach to teach essential competencies for working with people living with dementia. Simulation training provides experiential learning opportunities to enhance clinical training (Teasdale, Mapes, Henley, Lindsey, & Dillard, 2016). Simulation programs have long been a part of gerontological curricula to help students and younger individuals understand constraints faced by older persons, including sensory modifications to simulate diminished hearing and eyesight (Mosher-Ashley, 1996; Teasdale et al., 2016). Programs are often employed to promote empathy and understanding among learners.

The Virtual Dementia Tour

The Virtual Dementia Tour simulation is a one-time, one-hour sensory simulation. The experience involves “garbing” participants in items to replicate the sensory experiences of those living with a cognitive impairment and other comorbidities often experienced by individuals living with dementia (e.g., shoe inserts to replicate neuropathy found in individuals living with diabetes, a risk factor for ADRD). Participants are then given a set of simple tasks to complete in a designated simulation space for a timed period. This is followed by a debriefing period during which participants are told about behaviors they exhibited during the simulation and reflect on their experience (Beville, 2002). VDT has been demonstrated to increase sensitivity to the needs of individuals living with dementia among healthcare providers (Beville, 2002) and social work students (Donahoe, Moon, & VanCleave, 2014; Werner, Powell, & Clark, 2014). With its focus on sensory changes that upend daily functioning and the use of behavior monitoring, VDT implicates the Progressively Lowered Stress Threshold theory for understanding and intervening to affect BPSD. According to this theory, BPSD are a consequence of reduced capacity to cope with stress induced by sensory and environmental stimuli (Smith et al., 2004). Thus, participation enables students to anticipate sources of stress that may contribute to BPSD.

Transformative Learning

The success of VDT and other simulation programs may be attributable to their inclusion of components which stimulate transformative learning processes. According to transformative learning theory, learning processes are initiated following a transformative or disruptive event where learners realize their worldview is distorted (Kitchenham, 2008; Mezirow, 2016). Next, attitude and behavior changes occur following critical self-reflection about why distortions exist in one’s mind, an emotional process that often includes feelings of guilt. Critical self-reflection gives way to students’ identification of new criteria with which to construct their world view more accurately. Finally, behavior change occurs once students explore new roles for themselves based on their updated understanding of a phenomenon. Outcomes from transformative learning programs completed with healthcare trainees include increased empathy, confidence, and cultural sensitivity; these are critical skills that are required to administer person-centered care in clinical settings (Van Schalkwyk et al., 2019). The success of these program is attributed to their encouraging students to adopt viewpoints outside of their own to overcome prior assumptions. In the case of VDT, a healthcare trainee may hold a distorted understanding about why a person living with dementia behaves a certain way (e.g., they are mean person and dementia has revealed their “real” self). The simulation may disrupt this assumption. The debriefing then begins the process of critical self-reflection that precedes a modified, more accurate world view that is needed to provide dementia-competent healthcare.

The Present Study

While previous evaluations of VDT do demonstrate its effectiveness at changing attitudes, evaluations have primarily relied upon the program’s pre- and post-test assessment tools to measure changes in participants’ empathy for individuals living with dementia (Donahoe et al., 2014; Werner et al., 2014). However, these questions do not indicate how the tour improves understanding of dementia nor changes in participants’ abilities to deliver high quality healthcare to individuals living with dementia. Qualitative data can provide more nuanced information as to how dementia simulation learning improves healthcare students’ understanding of what it is like to live with dementia and how the program may affect delivery of care to people living with dementia. Using qualitative methods has been recommended to better understand how simulation learning increases participant insight and empathy (Mosher-Ashley, 1996). In this study, we build on previous evaluations of VDT by using multiple sources of data, including student reflection papers and in-depth interviews with students and faculty (Beville, 2002; Werner et al., 2014). In doing so, this study will respond to calls for additional research on the benefits of provider training on dementia care (Weiss et al., 2017). Thus, the purpose of this study is to answer the question: How does participation in a dementia simulation program contribute to healthcare students’ abilities to deliver person-centered care to individuals living with dementia?

Methods

Study Design

The researchers used a thematic analytic method to answer the research question and applied this approach to two sources of data: 1) in-depth, semi-structured one-on-one interviews with students who completed VDT within the previous 6-months and teaching faculty who included VDT into their courses, as well as 2) student reflection papers completed within 1-week of participating in VDT. Whereas interview methods were selected to allow examination of how students applied lessons learned from VDT given a time lag between program participation and data collection, document review of reflection papers enabled examination of students’ more immediate VDT experiences given a shorter recall period since participating in VDT. The study team was comprised of experts in healthcare education, dementia, simulation learning, and qualitative methods. Three members of the study team had prior experience delivering the VDT program to students.

Participants and Procedures

Students and Faculty In-Depth Interviews.

We conducted five interviews with healthcare students who participated in the VDT program and three teaching faculty from nursing, occupational therapy, and speech language pathology disciplines (Table 1.) Students who completed the simulation within the previous 6 months were emailed information about the study. Eight students were emailed, of whom 5 responded and completed an interview. Teaching faculty who included VDT as a part of their course were also emailed to determine interest in participating. All three teaching faculty who were emailed responded and completed an interview. Attempts were made to purposefully sample participants to include diverse perspectives according to field of study, demographic characteristics, and prior experiences caring for persons living with dementia. A study staff member scheduled an in-person interview individuals who responded and were eligible. Interviews were recorded and were transcribed verbatim and on a rolling basis, such that transcripts were reviewed upon their completion and data collection was discontinued once situation was reached.

Table 1:

Interview participants discipline background

Participant	Discipline	Years in field of study	Age	Race/ethnicity	Gender
Faculty 1	Occupational Therapy	2.5	39	African American	Female
Faculty 2	Nursing	14	65	African American	Female
Faculty 3	Nursing	8	60	White	Male
Student 1	Nursing	2	-	Hispanic	Female
Student 2	Occupational Therapy	2	25	White, non-Hispanic	Female
Student 3	Speech Language Pathology	1	24	White, non-Hispanic	Female
Student 4	Occupational Therapy	2	31	White	Female
Student 5	Nursing	2	22	Hispanic	Male

Semi-structured interview guides for students and faculty were drafted and circulated among the study team (Table 2). Questions asked about participants’ experiences during the VDT simulation, as well as how they believed the simulation would affect how they would deliver care to people living with dementia.

Table 2:

Semi-structured interview guide for students who participated in VDT¹

1. In what ways do you think the Virtual Dementia Tour will affect or has already affected your ability to deliver care to people with dementia in a clinical setting?

2. Why do you think that VDT will affect or has affected your ability to deliver care to people with dementia as a professional?

3. Has participation in VDT affected your ability to provide care to a family member with dementia, or how do you think it could it affect your ability to provide care to a family member in the future?

4. What was your experience after participating in VDT?

5. Who do you think could most benefit from participating in VDT among your peers or colleagues?

6. Do you think there are other ways you or your peers could learn what they do in VDT besides participating in this program?

7. Do you have any other thoughts you would like to share about how VDT has affected your ability to deliver care to people with dementia?

¹Follow up prompts were removed to preserve space. Faculty questions were reminiscent of those asked of students.

Student Reflection Papers.

Anonymous student reflection papers were prepared by bachelors-level nursing students within 1-week of completing the VDT simulation during a course (n=20), and were reviewed by the study team while interview data was being collected. Reflection papers provided a second source of data and enhanced the rigor of our findings through triangulation. For reflections, students were asked to describe their visceral experiences and reactions during the simulation, as well as how they would care for persons living with dementia differently following the simulation. Reflections were not graded, allowing students to freely express their experiences. Reflections were collected by a teaching faculty member who was not interviewed nor otherwise associated with this study.

Analysis

We applied a thematic analysis to the data, as this method allowed us the flexibility to code data both inductively and deductively (Braun & Clarke, 2006). After reviewing transcribed interviews and reflection papers, DJ and KM collaboratively devised a coding tree and definitions. Once members of the study team provided feedback on the initial coding tree, KM completed the first round of coding. Coding was completed using color-coded text in Microsoft Word documents corresponding to codes. Text excerpts were then organized by code in another Microsoft Word document such that excerpts falling under the same code could be evaluated for internal consistency. After completing the first round of coding, DJ and KM met to review each transcript and reflection paper and to discuss the appropriateness of the code applications and to identify emerging codes. All coding discrepancies were discussed until agreement was reached. A third round of coding was conducted to update all data files with codes that were added. (Analysis during the third round of coding occurred in NVivo for Mac to better accommodate the additional codes.) Results were discussed with the study team during a video-phone meeting. Each author had access to the drafted results section, all data, the coding tree, and a list text excerpts included under each code. Table 3 summarizes the steps taken by the research team to ensure study rigor and trustworthiness (Nowell, Norris, White, & Moules, 2017). This study was determined to be Exempt by the UT Health San Antonio Institutional Review Board.

Table 3:

Steps take to promote rigor and trustworthiness

Construct	Steps taken
Credibility	• Triangulation of data sources, including one-on-one interviews with students and faculty, as well as student reflection papers • Multiple relevant areas of expertise among researchers to design study and review analyses • Prior experience delivering the VDT program among researchers • Point of data saturation identified through transcription of interview recordings on a rolling basis
Transferability	• Purposeful inclusion of participants from different fields, with diverse demographic characteristics, and caregiving experiences • Use of “thick description” in summary of findings include in-depth quotes from participants
Dependability (auditability)	• Transcription of recorded interviews and retainment of original recordings, available to all members of the research team • Written annotations on printed transcripts and reflection papers during second coding round • Dated updates to coding trees and code definitions following each coding round, available to study team
Confirmability	• Review of 100% of study records in tandem by two study team members during second round of coding • Reflexive discourse during analysis between two study team members (e.g., examining positionality and potential biases)

Results

We identified three main themes about how dementia simulation may enhance the training of healthcare students. We also examined how well the transformative learning theory applied to students’ experiences.

Theme 1: Simulation Learning Meets an Education Gap That Traditional Teaching Methods Do Not Fill

You Can’t Get This in a Lecture or a Book

According to participants, the VDT simulation provided trainees with knowledge they may not learn using traditional teaching methods, such as lectures or textbook readings. Faculty members and students believed that the experiential aspect of this program enhanced student learning by showing students what it is like to live with dementia and common co-morbidities.

I guess you can read about dementia and we learn about it in class and you can read it in a book, but I think once you have [experienced] it, you know, you have to experience what they go through. (Student 1)

One faculty member compared difference between learning achieved through traditional teaching approaches versus VDT to students’ different learning styles:

It’s like that visual learner. Where if you see it, it brings it to light. Versus, you can read many things, and you can read the words, but yet, what does that mean? (Faculty 2)

The faculty member alluded to a sort of “Aha!” moment that students have during the simulation, where content learned in a classroom setting becomes meaningful, such that it can be applied to guide students’ future healthcare practice. This “Aha!” moment is analogous to the “disruptive” learning event described in the transformative learning theory.

At the same time, no one suggested that faculty abandon traditional teaching methods. Rather, these were believed to compliment delivery of the VDT. Simulation appears to extend learning beyond acquisition of knowledge, by helping participants more readily comprehend the lived experience of persons living with dementia.

When we use lectures with students in clinical and post-clinical, we do talk to students about what to expect when you’re taking care of patients who have dementia, what to watch out for and what strategies to take care of those patients, but not from the patient’s point of view. (Faculty 3)

Talking to Someone With Dementia and Family Caregivers Is Not the Same Thing

To assess whether the simulation really did fill a knowledge gap, we asked interview participants if they could think of other ways students could learn about what it is like to live with dementia. Several participants believed that talking to someone living with dementia and/or caregivers may accomplish this. Still, participants pointed out limitations with this approach. “I think that would be an alright idea,” said one faculty member, “But logistically it would be a nightmare” (Faculty 2). Some students expressed doubt that talking to someone living with dementia could reveal what it is like to live with this condition.

Yeah, I don’t know about getting the same effect. Because … talking to people that have dementia and talking to the caregivers will get you a step into that direction, but I don’t know about the same magnitude of being disoriented and confused and overwhelmed in that sense. (Student 2)

The emotional effects that the simulation had on students, set VDT apart from other empathy-building approaches, such as interacting with individuals who are living with dementia.

Theme 2: Understanding the Experience of Living with Dementia and Co-Morbid Conditions

Building Empathy

Students described feeling greater empathy for people living with dementia after participating in the simulation. They were surprised by how challenging it was to complete the simulation tasks they were instructed to do and realized that people living with dementia experience these challenges every day.

I had no idea it was this hard for people with dementia. These tasks are so simple for someone without dementia that we don’t realize what they go through on a daily basis. (Reflection 18)

Some students also described how a more developed sense of empathy elicited an emotional response, corresponding with critical reflection processes within the transformative learning process. Often this emotional response was related to students’ reflection on past behaviors towards family members living with dementia.

I think it just gave them a better understanding. You know, but it made them very emotional, you know, just really putting it together and understanding what their loved ones go through. (Faculty 1)

Interestingly, there was no single emotion that stood out when students described how felt when they reflected their and others treatment of people who are living with dementia. Students reported anger, sadness, and fear.

I’m angry at not knowing how this felt beforehand. I’m angry at myself for not being more empathetic with patients. (Reflection 13)

I felt sad that I didn’t empathize with my grandma enough when she struggled with daily tasks. (Reflection 5)

Theme 3: Applying Simulation Learning to Improve Practice

Students’ empathetic responses also gave way to ideas about how to apply new knowledge about the experience of living with dementia to improve the lives of individuals living with this condition and common co-morbidities. Within a transformative learning framework, this experience may be described as exploring novel roles for themselves upon adopting new understandings of what it is like to live with dementia.

But I think actually doing the VDT really got them to understand, “Okay this is what’s really going on with a person who has dementia.” So, I think it really helped them … it kinda sparked certain ideas about interventions, specifically for the patient but also for the caregiver. (Faculty 1)

This faculty member connected students’ new understandings of the lived experience of dementia with their ability to administer appropriate clinical interventions. Similarly, when the study team coded the kinds of practice applications students drew form this experience, we identified four main categories spanning practice- and systems-level change.

Being More Patient When Interacting with People Who Are Living With Dementia

The biggest lesson participants said they would apply to their practice was to be more patient. Students reported that the simulation showed them how much more time it takes to do everyday tasks when living with conditions that alter one’s senses, as well as how much more time is needed to process information such as verbal instructions.

This experience showed me how much patience is needed with people who have dementia. They are not being stubborn. They might not have just now understood the instructions or cannot do them correctly and are too embarrassed to ask for help. (Reflection 1)

Like many other students, the student’s recognition that practitioners need to have patience was a consequence of deepened empathy. The transformative learning processes is illustrated in this student’s experience. In this case, the student addresses an assumption she appeared to have regarding why older adults living with dementia behave in certain ways: sometimes they do not engage in expected behaviors because they are being stubborn. The simulation showed her an alternative reason: individuals living with dementia may not have heard what they are asked to do. Not only does she perceive how hearing loss affects behaviors, but also the social stigma of having to ask for help (“too embarrassed to ask for help”). Rather than attribute inappropriate behaviors to a personal flaw of the individual, the student re-evaluates prior assumptions and realizes these behaviors could be caused by factors she can address as a practitioner.

Assessing and Anticipating the Needs of Persons Living with Dementia

Besides being patient during interactions with people living with dementia and comorbid conditions, students indicated they were better equipped to assess when people living with dementia may need additional assistance following the simulation training.

I think that is the biggest thing is just understanding that because I gave instructions, and maybe they were listening and they nodded, that doesn’t mean “Yes, I understood and I know exactly what to do next.” (Student 2)

Many students describe that they had difficulty remembering the instructions for tasks they were asked to complete during the simulation. Several students wrote in their reflection papers that they pretended to understand instructions given to them during the simulation. Student 2, quoted above, appears to have taken this experience and connected it to the lived experience of people living with dementia. She recognizes that she may need to take additional steps as a practitioner to ensure her patients understand what she is saying. Similarly, another student shared how his recollection of the challenges he encountered in the VDT would help with “seeing forwardly”—that is, using knowledge about the lived experience of dementia to anticipate patient needs without their being expressed.

Like I had trouble getting the prescriptions into the bottle. So, I can kind of foresee that maybe with dementia or someone like that may not be able to do that. (Student 5)

Becoming an Educator to Family Members

Besides informing how participants would engage with people living with dementia on a one-on-one basis, students described how participation in the dementia simulation encouraged them to educate others, especially family members of those living with dementia. The hands-on experience gave students the language they needed to explain to family members what people living with dementia experience so they could better adapt their behaviors.

I also think it helps me to be able to verbalize more for what they’re going through … I think I would be able to tell my family members and have them understand a little better, like, that … I can tell them, “Yes, be patient” but I can actually explain: “This is what it’s like.” (Student 2)

As this student explains, participation in the simulation may strengthen their ability to explain to family members why they should accommodate an individual living with dementia by more precisely conveying that person’s experience. Not only was it important for students to educate families about the physical experiences of living with dementia, but also the emotional effects of these symptoms: “Not the medical aspect of dementia, but the emotional facets of confusion, frustration, hopelessness, and the disorientation and how these emotions affect them” (Reflection 6).

Creating a Culture of Care

Student participants also described how they would use what they learned to contribute to a culture of care—one where the dignity of individuals living with dementia is respected at a societal level. This is important since, in addition to providing direct services to patients, healthcare trainees also may become leaders in their organizations and communities to promote systems-level change.

The simulation has helped me think about skills I might use in the future as a leader/manager in helping staff be more aware of these kinds of patient situations. No patient should be left to feel powerless, hopeless, or alone as this simulation made me feel, and I think I will be able to enforce this belief in my future career as a nurse …. (Reflection 8)

This participant recalls her experience—feeling helpless—during the simulation to guide her planned behavior in a leadership position. She does not want the patients she and her colleagues serve to feel as she did during the simulation, and describes her intention to encourage others she may lead to prevent this from occurring.

Application of Transformative Learning Theory to Dementia Simulation Learning

We found evidence that partially supported the application of transformative learning theory when administering the dementia simulation. The simulation itself was experienced as a disruptive event. Students were affected not only on a cognitive level, but also physically and emotionally. Students described feeling disoriented, as well as physical discomfort. Several students reported feeling physical pain in their feet from the shoe inserts.

I couldn’t see, I couldn’t hear and, for the love of God, my feet were killing me. (Reflection 11)

The emotions students described while going through the simulation were wide ranging, and included anxiety, frustration, sadness, and embarrassment.

I felt frustrated and lost. I turned to the evaluator looking for guidance and couldn’t help but feel embarrassed. (Reflection 8)

It was not clear whether disorientation and physical discomfort effected emotional responses or vice versa, though we suspect this relationship was bidirectional given that emotional responses appeared escalate with students’ physical pain and sense of confusion.

Students’ learning experiences in the dementia simulation also diverged from the process described in Mezirow’s transformative learning theory. Whereas this theory suggests that guilt and shame follow disorientating experiences as one realizes their prior assumptions were incorrect, we did not observe this in all cases (Kitchenham, 2008; Mezirow, 2016). Rather, after the simulation, the participants appeared to engage in self-reflection, where they connected their experiences during the VDT simulation to that of those living with dementia, as well as society’s treatment of this population. Students described a range of emotions, such as anger and sadness. After making this connection, some trainees described feeling guilt about how they treated family members living with dementia.

Some of the students were very moved by it and they reflected on their own grandparents, and some of the students voiced that they wish they would have treated their grandparents better …. (Faculty 3)

We did observe participants imagining new roles for themselves as healthcare practitioners following their empathy response, consistent with the transformative theory process. Students imagined making modifications to their future or current practice, such as being more patient and becoming an educator for others. What is not known is whether students followed through with these action steps following the simulation experience and whether their learning converged with later stages of transformational learning steps. Figure 1 displays a modified model to describe students’ learning processes from a dementia simulation program, guided by transformative learning theory and what we observed in qualitative data.

Figure 1:

Learning process of healthcare trainees participating in the dementia simulation.

Discussion

In this study, we examined healthcare trainees’ experiences of a popular dementia simulation program to better understand how this program may affect future practice. The simulation elicited a mix of cognitive, physical, and emotional experiences within students which contributed to a stronger sense of empathy for those living with dementia. Heightened sensitivity to the experiences of those living with dementia enabled students to articulate specific actions they would take in their future practices. Overall, student’s experiences of the program were aligned with initial transformative learning stages, although we did not observe the same ordering or exact same experience across all students

Findings from this study echo those from previous studies which found simulation learning as a means to build student empathy (Lavallière et al., 2017), as well as sensitivity to the needs of individuals living with dementia (Beville, 2002; Donahoe et al., 2014; Werner et al., 2014). In a recent study, focus groups conducted with pharmacy students who participated in the VDT revealed very similar findings. In this study, students emphasized how the simulation addressed learning gaps that are not met using traditional classroom methods, and helped students to think about how they could better support people living with dementia through direct practice and at a systems-level (Gilmartin-Thomas et al., 2020). That we identified analogous themes using different sources of qualitative data with other types of healthcare students strengthens the findings of both studies.

In addition to upholding previous findings, results from this study suggest that participation in dementia simulation may promote a greater emphasis on interpersonal aspects of care among healthcare providers. Students described wanting to educate other clinicians and family members on the affective experience of what it may be like to live with dementia, in order to help them to understand why certain care practices are required (e.g., patience). Dementia simulation may weaken overly biomedicalized treatment of individuals living with dementia and balance this with a focus on social recognition and relational approaches to care (Kleinman, 2019; Lyman, 1989). The simulation also helped trainees realize why individuals living with dementia and related comorbidities may exhibit certain behaviors (e.g., muttering to self). In doing so, participants were given a first-hand experience of how Progressively Lowered Stress Threshold theory may apply—as sensory abilities are overwhelmed and affect emotional responses, it is normal to engage in seemingly unusual behaviors often construed as BPSD (Smith et al., 2004). Healthcare trainees with this experience may be better equipped to provide behavioral interventions to individuals living with dementia in the future.

Limitations

This study has several limitations. First, students participating in the study sample had not yet transitioned into employment settings where they could apply lessons learned from the dementia simulation. As such, interview content primarily focused on how students anticipated their practice approach would be affected. Further, this study focuses on the experience of occupational therapy, speech-language pathology and nursing students. We do not know whether students from other fields of healthcare would have described different experiences. We also acknowledge a potential reporting bias from the data sources we selected. Interview participants may have spoken favorably of their experience given the research team’s involvement in administering the VDT program. At the same time, students did not interact with the interviewer during the simulation, making this possibility less likely. Finally, interview data was collected up to 6 months following participation in the VDT program. It is possible that interview data was subject to recall bias. This risk was mitigated through triangulation with student reflection papers, which were completed within 1-week of participating in VDT.

Implications and Future Research

Future research is needed to test the effects of participating in a dementia simulation on future practice among trainees from multiple healthcare disciplines, as well as the applicability of the remaining steps of transformative learning theory. In particular, we would like to see research on whether participation affects students’ self-efficacy when managing behavioral and psychological symptoms of dementia, as prior studies indicate increase confidence as an outcome of prior transformative learning-based programs (Van Schalkwyk et al., 2019). Program efficacy should also be evaluated when administered with and without opportunities to use lessons learned in a clinical setting, as the final stages of the transformative learning process focus on application. Prior research demonstrates a strong positive association between clinical experience working with people living with dementia and students’ positive attitudes and knowledge, as compared to educational modules alone (Kimzey et al., 2016).

We also encourage further examination of two concerning features we observed in our data: 1) distress experienced by students during the simulation (Merizzi, 2018) and 2) students believing they know what it is like to live with dementia following participation in simulation. Students in our evaluation had ready access to counseling services, and program debriefings occurred with a nurse who had extensive experience discussing sensitive topics in practice and teaching settings. Thus, risk of student distress was reasonably managed within the study setting. In other settings, we recommend similar precautions to support students who may experience complex emotions related to the simulation (e.g., guilt over treatment of family members). To the second point, we noticed several students who believed they quite literally experienced what it was like to live with dementia, regardless of heterogeneity entailed with this condition (e.g., Reflection 18). To prevent this confusion, we encourage programs to provide VDT with traditional lecture-based teaching methods to ensure foundational knowledge about different types of dementia and co-morbidities, and to emphasize that no simulation will ever fully allow students to understand the lived experience of dementia.

Conclusion

Simulation learning provides healthcare trainees an opportunity to experience what it may be like to live with dementia and comorbidities. It provides a valuable transformative experience that allows students to put into practice lessons learned so they may provide optimal care. Students’ deepened sense of empathy appears to inspire intentions to deliver person-centered healthcare, and may equip trainees to better manage behavioral and psychological symptoms of dementia. As such, simulation may be an important and under-used tool to prepare future healthcare providers to serve a growing number of persons living with dementia.