Qualitative Study of Paediatric Advance Care Planning Through Simulation: How we did it and the Lessons Learned

Abstract

Simulation is a well-established experiential educational tool in health care, which allows clinicians to learn and practise skills via a replication of reality. However, its use as a research tool is novel and emerging. As we designed a phenomenological study of communication practices around paediatric advance care planning, we came to the view that simulation would be a very useful tool to enable feasible and ethical qualitative study of this complex and sensitive process, which involves discussion about a child’s death in the future and how to prepare for it. There is minimal description in the literature about how to use simulation as a qualitative research method. This article describes how we designed our study, focusing on: (1) the academic rationale for using simulation, (2) designing the simulation-based research method, (3) ensuring psychological safety of all participants in the simulation, (4) trialling the simulation, (5) the logistics of the study and (6) our reflections and learnings after using this novel method. We hope this discussion encourages other researchers to consider simulation as an innovative qualitative research method.

Keywords

advance care planning clinical simulation qualitative research design paediatric palliative care

Background

While there is a growing body of research about paediatric advance care planning (ACP), the challenge of conducting this research in ways that are ethically appropriate and feasible in practice exist. This is because of the complexity and sensitivity of this process. Paediatric ACP is a process of conversations during which doctors communicate their concerns about a child’s health status and limited life expectancy, and elicit parents’ values (and where appropriate, those of the child), in preparation for shared end-of-life decision-making (Aidoo & Rajapakse, 2018; American Academy of Pediatrics, 1994; Canadian Pediatric Society, 2008; Larcher et al., 2015; National Institute for Health and Care Excellence, 2016). This process differs from adult ACP in two key ways. Firstly, adult patients have decision-making capacity and are making treatment decisions for themselves (Hickman et al., 2005; Sudore & Fried, 2010); in contrast, children with life-limiting conditions usually do not have capacity (due to age, underlying illness or disability), so their parents are the decision-makers for them (Baker et al., 2015). Secondly, adult ACP is motivated to promote the patient’s autonomy by capturing their treatment preferences before the likely loss of capacity as their illness advances (Briggs, 2004; Hickman et al., 2005; Sudore & Fried, 2010; Tulsky, 2005). This is not the same in paediatric ACP since the parents as the decision-makers are not ill and are not going to lose their decision-making capacity. The motivation of paediatric ACP is to prepare parents (Vemuri et al., 2022). However, not all parents find this preparation acceptable (Liberman et al., 2014; Mitchell et al., 2019), and the challenge for paediatricians is to identify how much to engage parents in these discussions. Paediatric ACP often involves emotionally laden conversations and great care and skill is required to facilitate them; they can trigger grief and other strong emotions, create conflict within families or between families and clinicians and compromise therapeutic alliances. Despite being considered standard care for children with life-limiting conditions, the practice of paediatric advance care planning remains inconsistent (Baker et al., 2010; Dellon et al., 2010; Vemuri et al., 2018; Widger et al., 2007). Clinicians often feel under-equipped to manage these discussions (Basu & Swil, 2018; Durall et al., 2012; Heckford & Beringer, 2014; Lotz et al., 2015) and parents continue to feel under-prepared when faced with their child’s end-of-life phase (DeCourcey et al., 2019; Dellon et al., 2010; Meert et al., 2000). Research into ACP has been identified as a priority (Baker et al., 2015), and finding ways to meet the challenges of gathering data about these complex and sensitive interactions is also a priority.

While several studies have generated data from clinician’s self-reporting about their practice (Mitchell & Dale, 2015; Ruppe et al., 2013; Sanderson et al., 2016; Vanderhaeghen et al., 2019), these have obvious limitations. They provide evidence of clinician’s intentions and beliefs about doing ACP, but not about what happens in their consultations with parents. The methodological approach that offers the best opportunity to generate credible and trustworthy data would involve direct observation of ACP with audio- or video-recordings of interactions between paediatricians and families. However, naturalistic inquiry is problematic. These discussions are rarely planned so the time needed to observe and record a large number of interactions to capture relevant data related to ACP discussions may be logistically difficult. When these discussions do occur, it is often at highly emotional times (Carter et al., 2004; Kelly et al., 2018), which confers a potentially significant risk to parents to participate in such research.

Simulation offers an alternative to naturalistic inquiry (Vemuri et al., 2020). Research relating to clinical simulation has predominantly studied its effectiveness as a learning tool (Cook et al., 2011; Gurusamy et al., 2008; Issenberg et al., 2005; McGaghie et al., 2010, 2011; Sturm et al., 2008; Sutherland et al., 2006). However, there is increasing interest in conducting research on a range of clinical issues, using simulation as a method of data collection (Cheng et al., 2014; Munroe et al., 2016; Vemuri et al., 2020; Wong et al., 2017). Our systematic scoping review of literature related to the generation and use of qualitative data through simulation identified 46 relevant studies. These studies had either qualitative or mixed method research designs, and their research method explored simulation independent from the evaluation of simulation-based educational initiatives (Vemuri et al., 2020). This review identified that most of the studies did not name their underlying research methodology, provide their justification for using simulation, nor discuss potential implications of their research design on the trustworthiness of their findings (Vemuri et al., 2020). This is significant as transparency and appropriateness of the underlying theoretical framework and methods of data collection and analysis in research studies is needed to assess the trustworthiness of the interpretation of data (Dixon-Woods et al., 2004; Leung, 2015). While there is published guidance on designing simulation as a research method (Cheng et al., 2014; Munroe et al., 2016; Wong et al., 2017), there is a paucity of literature describing how such guidance has been implemented, particularly in qualitative research. No previous simulation-based qualitative studies have reported on the practicalities of using simulation in their research method. This article addresses this gap by describing how we designed a simulation-based qualitative study exploring paediatricians’ communication practices around ACP for a child with severe neuro-disability and what we learned from using simulation as a research method.

Academic Rationale for Using Simulation

ACP discussions do not occur often, and may arise spontaneously, rather than being planned by health care professionals. As a result, observation and recording of many interactions may be required to capture relevant data. This intrusion into the privacy of parents and paediatricians is also both logistically challenging and ethically problematic. Asking parents to consent to observation and recording of a consultation without them necessarily knowing the content of the conversation (limited disclosure with active concealment) is not ethically ideal. On the other hand, informing them that the study aims to capture ACP discussions creates significant risks, as this could change the nature of the planned consultation, and have secondary impacts for the parent, their understanding of their child, and their trust in their child’s paediatrician.

Given these ethical and logistical challenges, and the need for further research into ACP, we considered the use of clinical simulation as a qualitative research method. Clinical simulation mimics an aspect of care through the use of specific tools, devices and/or environments (Cook et al., 2011) and allows health care professionals to experience a representation of reality without the ethical concerns of harm, inadequate consent, and loss of privacy that arise in real-life situations. It is an established method to enable practice, learning, evaluation, or research (Cheng et al., 2014).

Our research adopted a phenomenological approach to explore how paediatricians created meaning and understood the reality of their lived experience of ACP (van Manen, 2007). Phenomenology was particularly well-suited for this study as our cultural attitudes towards death influence how we communicate about this with others and can lead to a myriad of reactions and assigned meanings (Heidegger, 1996). This methodology has previously been used to study phenomena related to individuals with life-limiting conditions (Seymour & Clark, 1998) and has been increasingly used in health care research (Biggerstaff & Thompson, 2008).

Clinical simulation has been used in a variety of qualitative inquires such as grounded theory, ethnomethodology, Think Aloud, Action Research (Vemuri et al., 2020), and most relevant to our work, phenomenology (Díaz et al., 2015; Ferguson & Cosby, 2017; Hodge et al., 2012; Johnson & Alhaj-Ali, 2017). It has been considered physically and psychologically more comfortable for clinicians and patients when compared to naturalistic inquiry into phenomena such as shared decision-making (Tsulukidze et al., 2015). As opposed to biomedical or technical phenomena, in which simulation breaks from reality through the use augmented reality technologies, the success of simulations which focus on communication relate to whether participants experience the emotion and thoughts of a real-life situation (Dieckmann et al., 2007). The simulation must be real enough to allow insight into the lived experience of participants and how they construct the meaning of a social phenomenon in practice (Dieckmann et al., 2007; Munroe et al., 2016).

Designing the Simulation-Based Research Method

Our approach to simulation development was informed by the study design features described in the simulation-based medical research literature (Cheng et al., 2014; Munroe et al., 2016; Wong et al., 2017). Our research question was how do paediatricians initiate and undertake ACP for children with life-limiting conditions? Prospective participants were recruited from across Victoria, the second most populous state in Australia, with 18 paediatricians included. Data were collected in the Simulation Centres at both tertiary paediatric hospitals in Victoria, The Royal Children’s Hospital (RCH) and Monash Children’s Hospital. Data included audio-visual recordings of the simulation and audio-recordings of the individual semi-structured post-simulation interviews conducted separately with the paediatrician and two actors. Data analysis for this study is in progress. The first round of analysis used thematic analysis of the post-simulation interviews (Braun & Clarke, 2006); later rounds will use conversational analysis of the audio data from the simulations (Bloor & Wood, 2011).

Scenario Development

We developed scenarios using the clinical experience of members of the research team: two who work as physicians in paediatric palliative care (S.V. and J.H.), and a third who works as a neurodevelopmental paediatrician (K.W.), in consultation with two medical subject-matter experts. These experts had more than five years’ experience working at consultant level in a tertiary paediatric centre: one in neurodevelopmental medicine, and the other in paediatric intensive care (ICU). The inclusion of subject-matter experts, in addition to the clinical research team members, was intended to ensure that the scenarios developed for the simulation were commonly encountered and relevant to the clinical practice of paediatricians working outside palliative care teams, as well as realistically representing an opportunity for ACP in practice.

Two scenarios were designed specifically to portray a clinical situation in which the paediatrician and parent-actor could be expected to have the type of interaction that the research question was targeting. The key features required in the scenario were: (a) a child who appeared to be sufficiently vulnerable to a shortened life that any paediatrician could appreciate their future was uncertain; (b) based on this concern about the child’s future the paediatrician would think about starting a discussion with the parents to share these concerns; and (c) the concern should not be so immediate that the paediatrician would be required to reorientate care goals or limit active or intensive therapies, or create resuscitation limitation orders. Two scenarios were needed, one in an outpatient clinic and the other in an inpatient ICU setting, to match prospective participants to a scenario based on the nature of their usual clinical practice. To check the face validity of the scenarios, two independent and internationally based paediatricians with relevant content expertise were asked to provide feedback on whether the scenarios we developed met our stated aims. By approaching internationally based paediatricians, we were able to ensure relevance in developed Western medical contexts outside Australia. Following confirmation of face validity, these two scenarios were captured in the RCH simulation template, which was developed by the RCH Simulation team for all communication-based simulated scenarios (supplementary files 1 and 2).

Enhancing ‘Realism’

Realism is a key consideration in the use of simulation as a research method. For research concerned with determinants of communication, the utility of simulation is influenced by how closely it represents reality (Dieckmann et al., 2007). Specifically, given the focus of this study was paediatricians’ approaches to communication, we prioritised psychological fidelity. Psychological fidelity seeks to enable participants to experience the emotion, beliefs, and thoughts of a similar real-life situation. This is distinct from physical and environmental fidelity which relates to the authenticity of the setting or simulation room (Dieckmann et al., 2007).

To help achieve psychological fidelity in our simulations we employed two medically trained actors, to play the role of parents of a child with severe neuro-disability. Each actor had at least ten years’ experience playing the role of parents of children with complex health needs in paediatric simulation-based educational initiatives. Actors have been used in a number of communication-focused simulation-based educational (Borghi et al., 2021; Meyer et al., 2009) and research activities (Aldridge, 2017; Bateman et al., 2016) to enhance psychological fidelity (Pascucci et al., 2014). The simulation template included actor character briefs incorporating a scale of emotional attributes, which is routinely included for actors involved in established, internationally adopted paediatric simulation-based communication skills training (Meyer et al., 2009). Furthermore, to inform these character briefs, we facilitated a full-day workshop involving five bereaved parents of children with severe neuro-disability and the actors. A detailed description of the experience of this workshop is outside the scope of this article, but in brief, the workshop allowed actors to listen to bereaved parents tell their own stories of making end-of-life decisions for their child (Vemuri, O'Neill, et al., 2022). The actors found this helpful in their character development for the parent roles they were to play.

Psychological fidelity was also enhanced by providing a plausible context for the scenario. Participants were told that they had not met this child and family before, for reasons that would be familiar from their usual clinical practice. They were also provided with a standardised written prompt for the simulated task, transfer of care letter, and inpatient observation chart and ward round note 5 minutes before they entered the simulation (either outpatient or ICU). This also enabled the research team to focus on how each paediatrician structured their initial communication with the family and laid foundations for a therapeutic relationship.

Some elements to enhance physical and environment fidelity were also incorporated. For the outpatient clinic simulation, the child was represented by a low-fidelity manikin in a wheelchair, and the room was set up like a clinic room with a desk and chairs. For the ICU simulation, the same low-fidelity manikin was placed in a hospital bed with a bi-level ventilation face mask applied, with chairs available in the room for the parents and paediatrician. As this study was conducted during the COVID-19 pandemic, the actors and each paediatrician wore surgical face masks reflecting the Infection Control guidance in place at the time. To achieve consistency between hospitals, we opted for paper charts instead of each hospital’s electronic medical record, as they differed.

Post-Simulation Interviews

Interview guides for the participating paediatricians and actors were developed (supplementary file 3). The interview guide for the paediatricians had four broad areas of inquiry:

• demographic questions;

• their overall communication approach and agenda in the simulation;

• their approach when there may have been a divergence of opinions between themselves and the ‘parents’ in the simulation;

• the use of simulation as the research method.

One of the aims of the post-simulation paediatrician interview was to obtain feedback on the fidelity of the simulation, so each paediatrician was asked about their experience of the simulation, and to reflect on their practice in this simulation as compared to reality. The interview guide for the actors had three broad areas of inquiry:

• their experience of the paediatrician’s approach;

• their understanding of the messages being communicated by the paediatrician;

• their experience when there was a potential divergence of opinions.

Ensuring Psychological Safety of Participants in Simulations

This study involved voluntary participation of paediatricians in a clinical simulation based on their current practice. Participants were experienced paediatricians entering into a situation which they knew was a simulation and were familiar with the research team in their professional capacities. The likelihood of significant psychological distress was therefore low, but not zero. In addition to the emotional nature of the study topic, it is important to recognise that being observed and interviewed by researchers familiar to them could potentially increase or decrease the feeling of psychological safety of the participants. Psychological distress may have been experienced as a result of participants feeling like their skills were being evaluated or judged (Edmondson & Lei, 2014). Furthermore, psychological distress may have been experienced as a result of recalling a case similar to the simulation, or if participants were struggling more generally with mental health issues (Edmondson & Lei, 2014; Meyer et al., 2009; Smith et al., 2018).

To mitigate potential risks to psychological safety, we highlighted these risks in the Participant Information Statement prior to written consent being obtained. Furthermore, M.H., a member of the RCH Simulation team (independent to the research team) attended the introductory discussion, where she highlighted these potential risks, provided reassurance that relationships would not be influenced by participation in this study, and outlined informal and formal avenues for support if needed. The post-simulation interview did not constitute a post-simulation debrief as used in simulation-based education, which is used to identify participant distress and provide psychological first aid if needed (Meyer et al., 2009; Smith et al., 2018). However, as a means of identifying the need for extra support, M.H. also attended the post-simulation interview as a non-participant, to screen for psycho-emotional distress arising from participation in the simulation. If identified, M.H. was able to provide emotional support, psychological first aid, and referral to formal psychological support services.

Trialling the Simulation

A pilot of each simulation and subsequent post-simulation interviews of participants and actors was conducted, with a neurodevelopmental paediatrician and a paediatric intensivist trialling the outpatient clinic and ICU simulation, respectively. Feedback from the pilot participants suggested psychological fidelity was achieved in relation to the study’s objectives, however, refinements were made to the physical set-up of the ICU simulation, and the introductory discussion prior to commencing the simulation and the post-simulation interview.

The first refinement was removal of a continuous monitor demonstrating the vital signs of the ‘child’ in the hospital bed attached to bi-level ventilation in the ICU simulation. This was because the pilot-test feedback suggested this was distracting and unnecessary, especially with monitor alarms further distracting from the communication between the actors and the paediatric intensivist. Feedback was also received that it was disconcerting to see a manikin rather than a real child with severe disabilities. Recognising the difficulties in rectifying this, both pilot participants suggested that there should be greater acknowledgement of this in the introductory discussion prior to commencing the study. In addition, the paediatric intensivist noted that it would be common practice to encourage parents to move away from the child’s bedside and into a separate meeting room when speaking with them or raising ACP. Given the physical limitations of time, space, and positioning of audio-visual recording devices, recreating this was not possible. Instead, feedback suggested acknowledging this in the introductory discussion. Further, actors were briefed to express a preference for staying by the bedside if offered the option of moving elsewhere by participants in the ICU simulation. Finally, we had planned to use sections of the visually recorded simulation to prompt discussion in the post-simulation interview for both the paediatricians and the actors. However, feedback indicated that viewing their ‘performance’ could be embarrassing and distract from participation in the interview. As such, video prompts were not used in the interview, and each interviewer (S.V. and J.O.) paraphrased participant or parent-actor statements in the simulation to help guide the interview. These prompts were identified during a pre-interview huddle of the four researchers who observed each simulation (described further below).

Logistics

The study was conducted over seven separate data collection days. Three data collection episodes (simulation and post-simulation interviews) were scheduled per day. Eighteen participants were successfully recruited between the 13^th April 2021 and the 24^th May 2021 despite pandemic pressures on clinicians.

Each data collection day started at 8:30a.m. and finished at 4:30p.m. and followed a detailed running sheet (Table 1). Initially, the simulation team member set up the simulation room (confirming camera and microphone positioning and functioning, and placement of the manikin in the hospital bed with a bi-level face mask in-situ in the ICU simulation) and interview room. The audio-visual recordings of the simulation occurred via different systems, given the differences in contracts with each hospital’s Simulation Centre. At the RCH, B-Line Medical SimCapture™ was used via portable cameras, while at Monash Children’s Hospital, StudioCode™ was used via cameras in-built in the ceiling of the simulation room, with audio amplified by using lapel microphones on the participants and actors.

Table 1.

Running Sheet for a Data Collection Day.

Time	Tasks	Key people
0845–0900	• Simulation set-up • Actors arrive and settle in	SV/MH JO
0900–0905	SESSION 1: Outpatient clinic scenario • Introduction and orientation to simulation suite • Provide instructions to participant	SV/MH
0905–0935	Simulated clinical encounter	SV/MH/JO/LG/JH
0935–0955	Participant moves to debrief room (escorted by MH) Actors break and refreshments Research team huddle to clarify key interview areas	MH SV/JO/JH/LG
0955–1050	Post-simulation interviews • Participant (debrief room) • Actors (Simulation room)	SV/MH JO
1050–1100	Time for further debrief if needed/Faculty debrief	SV/MH/JO/LG/JH
1100–1130	Morning tea break
1130–1135	SESSION 2: ICU scenario • Introduction and orientation to simulation suite • Provide instructions to participant	SV/MH
1135–1205	Simulated clinical encounter	SV/MH/JO/LG/JH
1205–1225	Participant moves to debrief room (escorted by MH) Actors break for refreshments Research team huddle to clarify key interview areas	MH SV/JO/JH/LG
1225–1320	Post-simulation interviews • Participant (debrief room) • Actors (Simulation room)	SV/MH JO
1320–1330	Time for further debrief if needed/Faculty debrief	SV/MH/JO/LG/JH
1330–1430	Lunch break
1430–1435	SESSION 3: Outpatient clinic scenario • Introduction and orientation to simulation suite • Provide instructions to participant	SV/MH
1435–1505	Simulated clinical encounter	SV/MH/JO/LG/JH
1505–1525	Participant moves to debrief room (escorted by MH) Actors break for refreshments Research team huddle to clarify key interview areas	MH SV/JO/JH/LG
1525–1620	Post-simulation interviews • Participant (debrief room) • Actors (Simulation room)	SV/MH JO
1620–1630	Time for further debrief if needed/Faculty debrief	SV/MH/JO/LG/JH

The actors and research team arrived at 8:45am, and the first participant arrived at 9am. As per usual simulation protocol, the actors and participants were kept separate before and after each simulation. Each participant was met by S.V. and M.H. and ushered into the interview room for the introductory discussion. They were then escorted into the simulation room to familiarise themselves with the setting by M.H. For the outpatient clinic simulation, the participant then remained in the simulation room, and the actors then ‘knocked on the door’ and entered the room to begin the simulation. For the ICU simulation, after familiarisation with the space, the participant was escorted back to the interview room, while the actors then set themselves up in the simulation room. The participant was then escorted back into the simulation room by M.H. to begin the simulation. The process of introduction was carefully constructed to mimic how the paediatrician and parent would be meet in the outpatient or ICU context.

Each simulation ran for approximately 30 minutes and was observed live behind one-way glass or on-screen by four researchers (S.V., J.O., J.H. and L.G.) depending on physical space and position of the simulation control room at each of the two hospitals. Contemporaneous notetaking of the live observation was used by the research team to help inform the post-simulation interviews. Following each simulation, the research team huddled for 10 minutes to clarify the lines of questioning based on the nature of the interaction between each participant and actors. During this pre-interview huddle, M.H. escorted the participant to the interview room and remained with them, while the actors remained in the simulation room for the post-simulation interviews and ‘came out of character’. Each paediatrician was interviewed by S.V., and the concurrent, separate interview of both actors was conducted by J.O. All interviews were audio recorded on hand-held voice recording devices and lasted between 30–60 minutes.

Following the post-simulation interviews, the participants were thanked for their time and escorted out of the simulation centre by S.V., after which the actors left the simulation room and had a refreshment break. At the completion of the interviews, the research team re-huddled in the simulation control room. In this re-huddle, S.V. and J.O. shared content that arose in the relevant interviews and any differences between responses from the paediatrician, actors and initial discussions of the research team were discussed. Notes of these critical multidisciplinary discussions were also taken by S.V., with this re-huddle also serving as a method to enhance the reflexivity of researchers.

Data Handling

Data from the audio-visual recordings of the simulation were captured via two different simulation programs across the two study sites. To store data uniformly for access to the research team, transfer from one system to the other was required. Transferability of data was more difficult for larger recording files, with size of the file directly related to the resolution of the video recordings. Unfortunately, our pilot test did not include this step in the research process, and we did not identify the default video settings on low quality resolution to enable quick export at one site. As a result, the video quality between sites differed. To prepare the data for transcription, audio from the audio-visual recordings of the simulation required separation and this was achieved using QuickTime™ to enable conversion into MP3 format required by the professional transcription service employed in this study. In contrast to this, data handling from the hand-held voice recording devices used in the post-simulation interviews was straightforward.

Reflections and Learnings from this Qualitative Simulation Study

When designing a communication-based study using simulation, the reliance on recreating a clinical encounter with adequate realism to achieve psychological fidelity with appropriate use of technology may be viewed with hesitation by some researchers. Concepts key to simulation, such as psychological and physical/environmental fidelity, can be unfamiliar to qualitative researchers. The number of possible variations within each simulation can be daunting. While at times it felt like doing more within the simulation (e.g. providing the real-time heart rate and respiratory rate of the 'child’, having the manikin’s chest rise and fall with the bi-level ventilatory support, or have vocalisations and noises come from the manikin) should enhance the sense of realism, this was not uniformly the case, as described above. The relationship between fidelity, realism, case quality and value of the simulation is not simple, and care and nuance are required in the research approach. Table 2 outlines key factors we identified for a successful simulation-based qualitative research study.

Table 2.

Key Factors to be Considered for a Simulation-Based Qualitative Study.

Careful crafting of a scenario to create an opportunity to study the phenomenon of interest

Fidelity (psychological, physical, and environmental)

Partnering with colleagues who are skilled in simulation

Use of highly skilled actors who are comprehensively briefed and informed by individuals with lived experience

Use of a research group huddles in real-time (e.g. pre-interview, post-interview)

Attention to promoting psychological safety of participants

Scheduling data collection days with a recognition of the intensity of data collection and its psychological demand on researchers

We relied heavily on the expertise of our simulation expert colleagues, not only in assisting in simulation design but also in the practical running of the data collection days. The simulation team members arranged the logistics of running the day and were required on multiple occasions to work-around issues with the recording technology (including on one occasion where an unforeseen blackout occurred in the Centre). Close partnerships with the Simulation Centres were essential and incorporation of funding for the Simulation Centres within research budgets is recommended.

Experienced actors were used to play the role of parents to facilitate psychological fidelity in this simulation. The skill of the actors and the participation of the same two actors in all interviews provided a high degree of consistency and realism. This was critical to the success of the simulation. It was also observed that the characters matured as the study progressed, and over time the actors started interviewing each other in their post-simulation interviews. They also offered the research team their analysis of the approaches to communication utilised by paediatricians after the individual simulations, along with comparisons to the paediatricians who had participated in preceding simulations. While we have not planned to formally involve the actors’ in our analysis process, this may enrich data analysis in future work.

The pre-interview huddle, which occurred after the simulation but before the post-simulation interviews, was a unique aspect of this study. It enabled the research team to discuss what occurred within the simulation and identify key areas to explore in the separate and simultaneous interviews with the paediatricians and actors. We allocated 10 minutes for this huddle, which provided ample time for a robust discussion to occur. It is important to recognise that while the research team was huddling, the participant often felt an urgent need to discuss or debrief their performance. Frequently, M.H. needed to distract the paediatrician with conversation on non-study related matters, to allow time for S.V. to finish the pre-interview huddle and commence the formal post-simulation interview. However, as important participant reflections were commonly shared during this time, M.H. would prompt the paediatrican to repeat these reflections, if not already shared, enhancing the richness and completeness of data.

As described earlier, the post-simulation interview was distinct from a the usual post-simulation training debrief, which seeks to allow participants to let go of emotions and discuss learnings in relation to the simulation aim and goals (Cheng et al., 2014; Meyer et al., 2009; Smith et al., 2018). Despite the research focus, it was imperative that there was some attention given to psychological safety within the post-simulation interview. We relied on the experience of M.H. in her capacity as a simulation educator to help promote this safety, in a manner that did not influence paediatricians’ participation in the interview. No instances of participant psychological distress were identified.

Conducting the study was resource and time-intensive, and psychologically demanding for the research team. Factors contributing to the psychological demand on the researchers included the intensity of observing the simulation, participation in the pre-interview huddle, undertaking the post-simulation interview, and then the re-huddle discussion on three occasions each day. Researchers were commonly exhausted at the end of the data collection day, especially when more than one was scheduled in the same week. Where possible, we would recommend spacing data collection days out by at least one week.

Conclusion

Through simulation, we were able to safely conduct rigorous research into ACP, a complex and sensitive process, that is of pressing importance to clinicians and families. In our exploration of this communication-based phenomenon, we focused on promoting psychological fidelity to enhance realism relevant to our research question and methodology. We expect that this approach will be of interest to qualitative researchers interested in other topics, as our approach has broad application. While the focus of such work is primarily to enhance the quality and delivery of care, there is also potential to include simulation in qualitative research training. Consideration of this aspect of applicability is outside the scope of this article and warrants further exploration as we continue to seek trustworthy and credible knowledge generated from qualitative approaches to research.

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Supplemental Material - Qualitative Study of Paediatric Advance Care Planning Through Simulation: How we did it and the Lessons Learned

Supplemental Material for Qualitative Study of Paediatric Advance Care Planning Through Simulation: How we did it and the Lessons Learned by Sidharth Vemuri, Melissa Heywood, Jenny O’Neill, Jenny Hynson, Katrina Williams and Lynn Gillam in International Journal of Qualitative Methods

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Supplemental Material - Qualitative Study of Paediatric Advance Care Planning Through Simulation: How we did it and the Lessons Learned

Supplemental Material

Supplemental Material - Qualitative Study of Paediatric Advance Care Planning Through Simulation: How we did it and the Lessons Learned

Footnotes

Acknowledgments

We would like to acknowledge the generous support of Ms Mirna Boujaoude and Dr Jenni Sokol from the Royal Children’s Hospital Simulation Centre, and Ms Andrea Wallace and Dr Ram Nataraja from the Monash Children’s Hospital Simulation Centre. We would also acknowledge the support of Dr Giuliana Antolovich for her assistance in scenario development and pilot testing, Dr Thomas Rozen for his assistance in scenario development, Dr Alyssia Haling for her assistance in pilot testing, and Dr Lucinda Carr and Dr Thomas Brick for their assistance in assessing face validity of the scenarios.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Melbourne Disability Institute at The University of Melbourne and the Bethlehem Griffiths Research Foundation (BGRF2007). In addition to this, we disclose that S.V. is supported by the Australian Government Research Training program, provided by the Australian Commonwealth Government and The University of Melbourne.

ORCID iD

Sidharth Vemuri

Supplemental Material

Supplemental material for this article is available online.

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