Living dolls and nurses without empathy

We first became interested in the use of simulation technology in nursing programmes when discussing the opening of a simulation laboratory in a large university a few years ago. A cast of hundreds of very important people looked on at the demonstration by academics and final year students of the impressive new technology. The ‘patient’ in question was a 44-year-old male, single parent who was experiencing crushing chest pain, diagnosed by the technology as a cardiac event. What caused us much consternation whilst observing the demonstration was that not once in the interaction did any attending ‘nurse’ acknowledge the anxiety the ‘patient’ would have undoubtedly been feeling, let alone address any of his likely emotional or psychological concerns. In other words, the actual person in the bed was ignored in favour of the technology and the purely physiological data it provided. The use of patient simulators, in this case, high-fidelity mannequins, is increasingly common in nursing education worldwide. It is used to support learning in a controlled environment, as an adjunct to clinical experience, an opportunity for students to practise their clinical skills outside the hospital environment. These are important factors given the decreasing number of clinical placement opportunities, the increasing risks associated with learning on real patients with much higher acuity than in earlier times, the cost of maintaining clinical placements and a more litigious environment where complaints against healthcare professionals are increasing. In addition, the technology offers savings on staff costs at a time of increased funding constraints. In other words, there are strong financial, legal and technological drivers at work, and these are arguably overshadowing pedagogical and professional considerations. The ‘technological imperative’ is likely also at work, offering a profession with some continuing insecurity of image a connection with the high status glamour of the new. The appeal is sweetened by financial incentives offered to universities by developers and providers of simulation technology. Authors such as Jeffries (2009) report that there is mounting evidence to support the majority of clinical learning taking place in simulated learning environments in the near future. At the same time as educators are embracing simulated learning environments, there is continuing concern about the quality of nurses’ communication in their professional practice, in particular, the inability of nurses along with other healthcare professionals to communicate in a compassionate and empathic manner with patients (Francis 2010, Bensing et al. 2013). Empathy is, at its simplest, an understanding of and identification with someone else's feelings. It involves compassion, responsiveness and understanding. It can be learned in a variety of ways and is aptly encapsulated in the well-known words of Atticus Finch in Harper Lee's 1960 novel To Kill a Mockingbird when he tells his daughter Scout, ‘You never really understand a person until you consider things from his point of view…until you climb into his skin and walk around in it’ (Lee 1990 p30). Empathy requires the ability to read and interpret non-verbal communication. Unsurprisingly, non-verbal communication is recognized as strengthening the nurse–patient relationship (Caris-Verhallen et al. 1999). Empathy includes, of course, moral sensitivity. Having empathy is a relational state. An ‘unconscious patient’ for example, is no different from, say, your partner being in Africa and not able to contact you – you do not lose empathy in your relational state because you cannot contact them but this presupposes you have empathy to begin with. There is no doubt that empathy is a multidetermined response that results from an integration of experiences to form a complex sense of concern for others. Evidence from as early as the 1970s demonstrates that empathic arousal precedes and motivates helping (Hoffman 1979). If we accept that embodied practices are important for the development of individuals and of empathic nursing practitioners, what if there is an absence of embodied practices? How might this play out in relation to the development of empathy? How might it impact on the interpersonal communication skills of nurses whose education is increasingly through the use of mannequins? Competency in communication skills is an intrinsic element of most health professionals’ education programmes, and effective interpersonal and communication skills are seen as important components of the delivery of health care (Boschma et al. 2010, Bensing et al. 2013, Moore et al. 2013). Furthermore, competency in communication is a requirement for registration as a healthcare practitioner in Australia and elsewhere (Australian Health Practitioner Regulation Agency 2014, Grant & Jenkins 2014). Poor communication has been implicated in increased patient dissatisfaction and complaints, malpractice claims, poor treatment adherence and negative health outcomes (Jangland et al. 2009, Bensing et al. 2013, Moore et al. 2013). Poor communication has further been seen as a breach of professional standards (Higgs et al. 2008). When using mannequins, students’ communication skills are tested when they are required to respond to voice-over technology which comes from a faculty member or another student speaking as the patient, from a control room. It has been suggested that because the response to the voice-over technology is made to a plastic mannequin that does not exhibit any non-verbal behaviour, it will inevitably be artificial and superficial, rather than reflecting a genuine attempt to relate to patients in an empathic and caring way (Case & Brauner 2010). Further, Wear and Varley (2008) suggest that whilst students using simulation technology are often assessed according to a checklist of behavioural manifestations of empathic and caring behaviours, there is no way to assess sincerity or authenticity. Seropian (2003) suggests that it is impossible to translate simulated experiences to the real-time interplay of complex real-life experiences. O'Hagan et al. (2014) recognize that there are many factors impacting on the nurse–patient relationship which cannot be taken into account when checklists are relied upon, for example, authenticity: is the interaction genuine or even effective? A 2012 report from the USA which surveyed 1,729 nursing programmes found that one third of the respondents felt that communication cannot be learned by simulation technology (Kardong-Edgren et al. 2012). Recognizing the difficulties of developing empathy in students using mannequins and the lack of best practice guidelines for teaching with mannequins, Kardong-Edgren et al. (2012) have called for urgent research into the use of patient narratives in conjunction with simulation scenarios. Teherani et al. (2008) also recommend combining human patient simulation with narrative inquiry and personal reflection exercise. The risk in the increasing use of this style of learning is that it may favour the technical, the data driven, and the atomistic, in place of a more holistic, patient (human)-centred approach. This is seen to have a possible impact not only on the emotional intangibles of the nurse–patient relationship but also on actual clinical outcomes. There is evidence now that in the use of simulation technology for teaching in the aviation industry and in medical training, the learning can actually result in negative learning – not even neutral learning (Gilpin 2015). With respect to medical training, classical presentations used in simulation are often not transferable to actual clinical settings where the majority of patients do not present as ‘typical’ and they unwittingly introduce mechanical and physiological negative responses when transferred to the clinical setting (Gilpin 2015). Artificial intelligence has found its limits in trying to replicate empathy. It is unlikely that a computer that can genuinely laugh or cry will ever be created and as empathy is recognition of the other – something beyond a rule – based programme – it is difficult to see artificial intelligence's place in developing caring, compassionate behaviours in the educational setting (Abascal et al. 2006). The best nursing practice takes into account the unique and subjective patient experience and is grounded in effective communication skills including empathy. There is evidence that empathy is not supported by clinical practice in laboratories using ‘machine’ patients. Effective nursing does not separate technical, knowledge-based learning and the interpersonal dimension but instead takes an integrated approach. Nurse educators should acknowledge the limitations of mannequins in the education of nurses, particularly in the area of empathy. Educators are well placed to examine alternative and supplementary strategies so that this fundamental aspect of nursing is not diluted. To date, there is a lack of evidence-based research into the use of simulated learning environments in nurse education (Sanford 2010). Further research on the use of simulation using mannequins will help identify deficiencies and lead to interventions founded on a strong evidence base. The negative learning risk of using simulation technology in nursing education should be open and quantified and subject to peer review.