Field Educator: A Scholarly Journal from the Simmons University School of Social Work

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Introduction

Holland Bloorview Kids Rehabilitation Hospital’s (Holland Bloorview’s) innovative Social Work Simulation Education Program uses trained actors in simulated scenarios to enhance the acquisition of social work skills and competencies and engage students in higher level learning. Simulation is described as “a pedagogy using a real world problem in a realistic environment to promote critical thinking, problem solving, and learning” (Nimmagadda & Murphy, 2014, p. 540). Social work simulations enable students to learn how to integrate social work theory, knowledge, skills and values into practice. Use of this pedagogy in the field provides students with opportunities to practice clinical skills and actively engage in reflective practice activities so that they feel more confident and competent as they begin to provide services to clients. It also promotes learning about the organization’s programs and services as well as professional practice standards and ethics.

Context

Holland Bloorview is Canada’s largest pediatric rehabilitation hospital that provides services to children, from birth to 19 years of age, who have disabilities and ongoing complex health needs. This includes children who have cerebral palsy, acquired brain injury, muscular dystrophy, amputation, epilepsy, spina bifida, arthritis, cleft-lip and palate, autism and other developmental disabilities. Holland Bloorview is committed to client and family centered care and is a leader in healthcare research and education. It is one of the first field placement settings, affiliated with the University of Toronto Factor-Inwentash Faculty of Social Work (FIFSW), to formally use simulations in field education (M. Bogo & E. McKee, personal communication, April 9, 2015). Simulations using actors, referred to as standardized patients or clients, have been used to teach social work students and to assess skill development in the classroom (Badger & MacNeil, 2002; Linsk & Tunney, 1997; Logie, Bogo, Regehr, & Regehr, 2013; Petracchi, 1999). They have also been used by FIFSW in the form of Objective Structured Clinical Examinations (OSCEs) to evaluate competence (Bogo et al., 2011; Bogo, Rawlings, Katz & Logie, 2014).

Holland Bloorview’s Social Work Simulation Education Program is run once a year. Student performance is not graded and feedback is not provided to practicum supervisors for inclusion in student evaluations. To date, the program has run twice and has involved a total of eight students. Four Holland Bloorview social workers (three from outpatient and one from an inpatient program) worked collaboratively to develop simulation vignettes for the program that are reflective of challenging client situations commonly encountered by social workers in the organization.

Rationale

Kolb’s (1984) experiential learning theory explains that learning is most meaningful when it occurs through concrete experience, reflective observation, abstract conceptualization and active experimentation. Learning and mastering social work skills takes practice, and simulations offer a great opportunity for experiential learning. Simulations enable students to apply the Integration of Theory and Practice Loop (Bogo & Vayda, 1998) which reinforces the idea that learning occurs through doing, reflecting, thinking, and doing again. Research shows that deliberate practice of a skill is positively correlated with greater proficiency (Ericsson, Krampe, & Tesch-Römer, 1993). A study of social work students in field practicums showed that students who engaged in more frequent practice of skills rated themselves as more competent in their areas of practice, reported better average performance and more satisfaction with field practicums. They were also rated as more skillful by their field instructors (Fortune, Lee, & Cavazos, 2007). In the healthcare field simulations designed to enhance the development of clinical skills and allow for learning from errors have been used in nursing (Galloway, 2009) and medical education (Ziv, Wolpe, Small & Glick, 2006) so that students could practice skills without risking patient safety.

Format

Social work students at Holland Bloorview are informed that the purpose of the simulation program is to provide them with opportunities to work on foundational social work interviewing skills in a safe and confidential environment. The students are encouraged to learn with and from one another, to have fun, take risks, ask questions and share their concerns. They are informed that each social work simulation session is scheduled for three hours, once a month, over a three-month period, and that the simulations are facilitated by one or two experienced social work field educators.

Every three-hour session allows time for each student to participate in the role of a “social worker” in two separate simulation scenarios with a half hour break between the two simulations. The students are informed that they will each have approximately 10 to 15 minutes to work with a standardized client in a clinical interview and that if they feel stuck or uncertain about what to do that they can “time out” at any point. It is also explained that, for learning purposes, the facilitator can time them out at any point. Students in the non-social worker role are asked to participate by acting as “observers” and noting what they think the student in the social worker role does well and what can be improved. Prior to the start of each simulation the students are provided with a written case vignette that includes a reason for the social work referral and learning objectives. The students are given an opportunity to review this information, ask questions, address concerns, and raise issues of interest to them.

Collaborating with and preparing the actors for each simulation scenario is essential to ensure positive learning experiences for the students. The actors for the simulations are recruited from the University of Toronto Standardized Patient Program (University of Toronto, 2016). Prior to the start of each simulation, a 15 to 30-minute meeting is held with each actor to share information about the vignette, learning objectives, and emotional intensity required to achieve the learning objectives. During this meeting the actor has an opportunity to share their thoughts, ask questions and clarify information.

The vignettes

Six vignettes, each focusing on a different issue, were developed. Themes common to the vignettes were identified for practice: (1) working with intense emotions (an angry client, a sad client, and a couple struggling to cope with their child’s new diagnosis and a possible marital separation); (2) developing and maintaining professional boundaries and ethical practice (a teen coping with bullying who requests that this be kept confidential, a client who attempts to develop a dual relationship which is defined as a therapeutic relationship and a friendship with the social worker); and (3) demonstrating sensitivity to diversity and cultural differences (a mother advocating for “better care” that is more aligned with her cultural values).

To simulate the experience of ongoing work and continuity of care with a client, the program is structured so that the same standardized client participates in three different scenarios (angry client, mother in the couple struggling to cope with their child’s new diagnosis and a possible marital separation, and client who attempts to develop a dual relationship). These three simulation scenarios are scheduled consecutively, one each session per month, over the course of the three-month program.

Learning Objectives

A primary learning objective for the students in their assessment, goal setting, and intervention work with each standardized client is the development of a therapeutic relationship. Explaining the social work role, discussing confidentiality and its limits, and obtaining consent for assessment and intervention from clients are consistent with social work professional practice standards and are organizational imperatives at Holland Bloorview. Developing and demonstrating competence in these tasks are learning objectives for the initial simulations. For these simulations, each student in the social work role is asked to begin the simulation as if he/she is meeting the client for the first time. In subsequent scenarios, students are given the choice of starting the interview from the beginning or picking up the interview from where the last student finished.

For all six scenarios the students are asked to demonstrate interviewing skills and behaviors that foster the establishment and maintenance of a therapeutic alliance such as: active listening, use of open ended and close ended questions, reflection, validation of client experiences, clarification, focusing the interview, demonstration of empathy, recognition of client strengths and showing respect (Bogo, 2006; Duncan, 2014; Kourgiantakis & Bogo, 2015a; Kourgiantakis & Bogo, 2015b). The importance of the therapeutic alliance is indicated in over 1000 research findings (Orlinsky, Ronnestad & Willutzki, 2004). Better client outcomes are correlated with positive therapeutic alliances (Horvath & Symonds, 1991; Lambert, 2010; Martin, Garske & Davis, 2000). It is important for practicing clinicians and students to be aware that, “the amount of change attributed to the alliance is five to seven times greater than that of a specific model or technique” (Hubble, Duncan, Miller & Wampold, 2010, p. 37). Strengthening alliance building skills provides social workers with an avenue to maximize therapeutic success and optimize outcomes.

Debriefing

Debriefing promotes the development of reflective practice. After each simulation the standardized client provides feedback to each student. Following this, the standardized client leaves the room and the field educator engages the students in a group debriefing. This involves identification and discussion of each student’s demonstrated areas of strength, challenges experienced, and areas for improvement. As students engage in this process they learn about receiving and providing feedback to others.

Issues discussed by the students during debriefing periods included: use of self, how their thoughts and feelings influenced their actions, transference issues, application of theories to practice and therapeutic approaches. Theories discussed included: ecosystems, family systems, family life cycle, anti-oppressive and role theory. Therapeutic approaches discussed included: motivational interviewing, cognitive behavior, strengths based, and solution focused therapies.

A final group debriefing is held at the conclusion of each three-hour session. At this time further discussion is had about any issues of interest or concern to the students and feedback for future sessions is sought. A ‘start, stop and continue’ approach has proved to be useful for obtaining feedback about the session.

Video Recording

At the request of a student, and with the consent of the standardized clients, a video recording was made of the simulation session of the couple. The students were able to review this recording individually, at their convenience, and as a group. Video recording is an excellent educational tool as it allows for in depth objective analysis of demonstrated skills and behaviors, both verbal and non-verbal, and eliminates the need to rely on memory and recall which can be unreliable and selective (Iverson, 1986; Robinson & Kelley, 2007). Video-recording also helps students to link theory to practice (Burnard, 1991; Dixon, 2013; Dorr, 2014) and promotes the development of reflective practice (Bennett & Dodge, 2014).

Student Reflections

A social work student reflecting on her experience commented:

Compared to my simulated experiences at school, the format of the simulations in my field placement was more conducive to my learning. I appreciated that these simulations occurred in a small group, and that the facilitators had vast experience in the field setting. Facilitators emphasized that the purpose of the simulations was to learn together and develop a level of comfort working at Holland Bloorview. The simulations were much less stressful and anxiety-provoking than the ones I had done in the classroom. That’s not to say that going into the simulations my anxiety level was at zero – I was still practicing in front of my peers with situations intended to challenge me.

In reference to the benefits of the experience the student explained:

I feel that I experienced significant improvement in my skills and developed insight into my abilities through the Social Work Simulation Education Program. I noticed growth in the areas of questioning, assessment and my ability to empathically connect with clients. The simulations also allowed me to work through and discuss some of the fears and concerns I had in working with children with complex medical needs. Most significant to me was the confidence I developed in myself as a social worker. I learned to trust that I had the skills to help clients make change. Whenever I have doubts about my clinical abilities, I can look back on the simulations and remind myself of the positive feedback I received from my peers, the facilitators and the standardized clients.

Field Educator Reflections

As an experienced field educator it was very rewarding to see the high level of engagement in student learning that occurred during the social work simulations. I was surprised by the open discussion and the high levels of anxiety that the students reported they were experiencing working with standardized clients and with real clients in the placement setting. I was pleased that over the course of the three-month simulation program the students reported an increase in their feelings of confidence and a decrease in their feelings of anxiety.

I observed significant improvement in every student’s interviewing skills and reflective practice abilities. I was pleased to see that the students could identify and discuss social work skills and competencies in a professional manner as well as issues related to use of self and professional practice standards and ethics. Specific discussion was had about the Ontario College of Social Workers and Social Service Workers (OCSWSSW) Code of Ethics and Standards of Practice. The students also learned about organizational policies, procedures and programs such as infant development, therapeutic recreation and respite. In addition, they learned about services provided by other allied health professionals such as psychologists, occupational therapists, physiotherapists and speech and language pathologists.

Future Research

Research is needed to determine the benefits of social work simulation education in the field and its place as an evidence-based best practice model for teaching and learning. Comparisons of competence, confidence, and anxiety levels in students who participate in simulations in the field and those who do not may provide important information about this pedagogy. Comparisons of student competence in the field and quantification of the benefits of field-based simulation to the organization, field educators, and clients would provide evidence to justify the cost of hiring standardized clients for education purposes. As well, studies examining the impact of field-based simulations on preparedness to enter the workforce may benefit organizations and their clients.

Conclusions

The students who participated in Holland Bloorview’s Social Work Simulation Education program agreed that working with standardized clients enabled them to practice clinical skills in real time without the fear of causing undue emotional or psychosocial harm to real clients. They reported that the simulation vignettes helped to prepare them to work with real clients at Holland Bloorview as all the vignettes focused on relevant issues and highlighted situations commonly encountered by social workers in a pediatric rehabilitation facility. The students identified the Simulation Education Program as one of the few opportunities in the field that they had to practice skills together and to learn with and from each other. They noted that participating in the simulations enabled them to develop a strong comradery and build a support network that lasted for the duration of their placement. The students agreed that the simulation program provided them with safe space in which they could share their placement experiences, their doubts and concerns, and their successes with clients.

Knowledge exchange about experiential learning methods in field education is important to social workers who strive to offer high quality placements to students and advance best practices in social work education. One student remarked that participating in the social work simulations was “by far the most powerful and meaningful learning experience” he had as a social work student. Student feedback indicates that participation in the social work education simulation program enhances the social work student experience at Holland Bloorview, supports Holland Bloorview’s commitment to Client and Family Centered Care and contributes to best practices with clients and families.

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