Soft skills, which encompass many elements of emotional intelligence, combined with clinical competency, are the hallmark of a master healthcare provider and flow effortlessly within a patient interaction. Emotional intelligence, compassion, communication, empathy, leadership, self-awareness, cultural competency, confidence, self-regulation and more, have been identified as essential elements which make up the soft or non-technical skills of a clinician delivering quality, patient-centered care (Liebrecht & Montenery, 2016). Educational institutions increasingly seek to incorporate curricular content emphasizing the development of these elusive soft skills in their students.  One of the most effective ways to teach these skills to healthcare providers is through service-learning (Moran et al., 2015; Pechak, Gonzalez, Summers & Capshaw, 2013). To reduce the stress experienced by providers while serving in under-resourced environments, as well as ensure mutual benefit for the host community, adequate pre-departure training (PDT) is essential.

A single exposure to crisis using simulation can significantly improve the nontechnical skills of anesthesia residents (Yee et al., 2005). Evidence suggests that adding simulation to PDT will better prepare providers to resolve ethical and cultural dilemmas (Ekelman, Bello-Haas, Bazyk, & Bazyk, 2003; Mu et al., 2016) while facilitating soft skills (Johnson & Howell, 2017; Buff et al., 2015). However, it has not yet been utilized for an interprofessional PDT of rehabilitation providers. We hypothesized that the use of simulation for pre-departure training could improve the soft skills of physical and occupational therapy students and clinicians providing rehabilitation services on a one-week service-learning experience in Guatemala.

Simulation Curriculum Development: A 20-minute simulation scenario was developed for one pre-departure training. It centered around a case requiring two English-speaking student therapists to teach a Spanish-speaking caregiver of a wheelchair dependent child how to perform stretches to improve mobility and quality of life. The goal of the simulation was to teach appropriate communication utilizing a translator and to allow students to exhibit empathy in a culturally-stressful situation. The topic was selected based on previous interactions with patients from earlier trips to this destination. Table 1 lists the simulation case and learning objectives, that are based on global health competencies for health providers (Jogerst et al., 2015).  A 30-minute debriefing followed the simulated experience.

Participants: A convenience sample of 21 physical and occupational therapy students and clinicians who participated in four 1-hour PDT sessions before traveling to Guatemala were included in this qualitative study using grounded-theory methods. Informed consent was obtained from all participants once accepted to the service-learning project. They were made aware that participation in the study was independent of the project, there was no obligation to participate, and they could withdraw at any time. Pre-departure training consisted of didactic, reflective and simulation components designed to introduce self-awareness, team-building, cultural knowledge, and trip preparations. All training occurred face to face and via Skype for team members who were not physically able to attend. To be included in the study, all participants had to attend 100% of the training. Twenty-five participants began in the study, but three were excluded for not attending all the training. Ethics approval was granted by the Institutional Review Board of The University of St. Augustine for Health Sciences (UR-0809-228). Written and verbal informed consent was obtained from all participants before each stage of data collection.

Debriefings: Four total debriefings were recorded using open-ended questions with a thematic approach. The first briefing occurred before the PDT.  The second occurred after the simulation. The last two debriefings occurred at the first and final day in Guatemala. Debriefing topics addressed cultural preparedness, adaptability, inter-professional collaboration, problem-solving, teamwork, and impact on professional development.  These themes are considered a priori in that they are current topics that have been identified in association with global health education (Josgerst et al., 2015; Logar, Le, Harrison, & Glass, 2015; Ventres & Wilson, 2015). Participants had the opportunity to share what they learned, ask questions, and express their feelings regarding their experience working in the Guatemalan community, and specifically how simulation prepared them for any experiences that were encountered during the week.  Participants excluded from the study were asked to refrain from the recorded discussion. However, they were encouraged to share after the study participants were recorded, to not invalidate the debriefings. The dependent variable was subject preparedness and adaptability. The independent variable was a 20-minute simulation emphasizing cultural and socio-emotional challenges of the host community.

Data Analysis: Transcription of the recorded debrief sessions were executed verbatim without subject identification. Transcript review and thematic coding were performed independently by both researchers followed by several meetings at various intervals. A priori coding using the thematic areas identified previously were observed; however, the researchers were also aware of emerging themes. Two-member checking was used to confirm the meaning of the dialogue during the review so that the themes that emerged were accurately reflected (Cresswell & Plano Clark, 2011).

Six themes surfaced: confidence, empathy, communication, mentorship, self-knowledge, and cultural competency. The themes described were core elements of empowering providers towards advocacy and process improvement. Participants reported that the simulation experience resulted in an improved ability to respond to distressing situations and utilize soft skills. Table 2 represents participant feedback to support the themes.

Overall, the qualitative data suggest that the pre-departure simulation experience helped our participants better respond to distressing situations during the week in Guatemala. One theme that appeared early in the debriefing sessions was confidence. Confidence boosting following healthcare simulation experiences is well-supported in the literature. Ohtake, Lazarus, Schillo, & Rosen (2013) noted significant increases in student physical therapist’s confidence levels following a simulated patient treatment session. Consistent with Ohtake et al.’s (2013) findings, study participants relayed a better understanding of work pace and possible clinical scenarios they would be facing in Guatemala following the predeparture simulated patient encounter. A more concrete understanding of the complex cultural and ethical challenges faced by patients in an under-resourced environment led to one participant’s expression of improved confidence level for the upcoming service-learning experience:

“The point I’m trying to make with this is that it ‘simulation’ helped me realize what I’m going into in another month and understanding that it’s certainly a quick pace.”

Psychosocial role-playing has been used to improve the soft skill responses of nursing students to emotionally challenging situations (Liebrecht & Montenery, 2016). Liebrecht & Montenery (2016) concluded that “this increased awareness and insight allows students to respond in a more comforting, helpful, and professional manner in the clinical setting.” Responding empathetically to the patient in a moment of distress was a highly evident theme within the participant dialogue. Specifically, student participants initially demonstrated a complete lack of response to a culturally novel and emotionally charged situation within the simulated encounter. One student participant revealed the following in the debrief immediately following the simulation encounter:

“I felt like I was kind of like deer in the headlights. I had that feeling and then I also, like when she started crying like I didn’t know what to do, and I would say I am a very empathetic person, but for some reason, I just stood there. I know I think it was the nerves and just not being in that situation before and, also the language barrier.”

However, while onsite in Guatemala, student participants were able to respond in a highly empathetic manner when faced with a similar situation. One student participant commented during the week of service:

“ When the mother started crying, like I realized we’re all standing in front of her staring at her and she was crying, so I go over and just put my arm around her, and it was just maybe like a hug, but she wraps her arm around me and holds me for the rest of the time she is talking.”

On the continuum of empathetic interaction in patient care, Lown (2014) found self-regulation of one’s emotional responses to be essential to providing appropriate and effective care.  While the goal is to build highly empathetic, culturally compassionate providers, they must also be able to manage emotions, to act in the patient’s best interest. Student participants indicated a reconciliation of self-regulatory responses between the simulated encounter and the service-learning experience noting personal growth in this skill as a result. One student participant reported the following:

“From the sim lab, it was just really, real because (today in the clinic) there was a patient telling me about her history of abuse with her husband, and how he broke her ulna in a fight. And so, I had to really kind of control my empathy, you have to really keep it in check.”

Skillful communication is widely regarded as the mainstay of patient safety. Research has shown that simulation can be effective in enhancing communication skill development by promoting active listening (Kim, Ko & Lee, 2012). All participants in our study consistently expressed concerns with the communication language barrier in anticipation of the upcoming travel.  For many of the participants, the simulated encounter was their first experience working with an interpreter in the clinical environment.  One clinician participant advised immediately following the simulated encounter:

"when you're asking a question, looking at the patient, not the translator, really looking into their eyes and whenever they're answering."

Another student participant commented during the week in Guatemala:

“So, from that (the simulated encounter), I learned that it’s OK to stop what you’re doing and to be with that person because they are human. You don’t have to just be ‘OK, I have to get my job done. I can’t talk to you.  So, it was kind of cool to set down the paintbrush and just have this conversation and get to know her better and make that relationship.”

Themes around mentorship emerged from both the student and clinician participants during the entire experience as the more experienced students and clinicians were mentoring the newer participants.  For example, during the simulated encounter, one supervising clinician overstepped her role of simply providing student guidance.  A decision was made from the control room to remove her from the simulation and allow the students to work through the scenario more independently. The clinician commented that she did not even realize she was directing the scene:

“I didn’t feel like I was stepping in and then they pulled me because I was doing too much. I need to let you do more without stepping in.”

Her commentary demonstrates growth in mentorship skills which carried forward into the onsite learning experiences in Guatemala.

Self-awareness of one’s strengths, weaknesses, and background within the context of a global perspective emerged as a predominant theme.  Participants expressed awareness of their limited exposure to diverse cultural and socioeconomically deprived environments after the simulated experience and more so once on site in Guatemala.  Self-knowledge is commonly thought to be the initial stage of personal growth, and participants expressed the service-learning experience, supported by the simulation experience, stirred significant maturation within them.  One student participant commented on the final day in Guatemala:

“the personal growth is just even more eye-opening, but I always try not to judge a book by its cover. …like just taking a step back and really make sure you don’t judge because you never know when someone had just an awful experience."

One of the best ways to teach cultural competency is through service-learning (Ekelman et al., 2003; Mu et al., 2016; Johnson & Howell, 2017). Logar et al., (2015) suggests that to maximize student preparation for international service-learning, simulation that uses scenarios that engages students with the ethical dilemmas and distinct cultural challenges of the host community should be implemented.  Students strongly expressed that, while nothing can wholly prepare them for the intense cultural differences experienced while on a service-learning trip to a resource-limited country, the simulation activity contributed greatly to their feelings of preparedness.  One student participant commented:

"I do feel prepared, but coming to a completely different…world from where we live… I was faced with stories and situations that just still blow your mind and break your heart and I cried….. I do feel prepared but also it opened your eyes and there's just some things that you just can't totally be prepared for."

Systematic approaches are needed to help new and experienced healthcare providers develop and maintain the soft skills required to deliver compassionate care (Lown, 2014).  Whether at home or abroad, moving from cultural awareness to cultural competency and further still to cultural compassion is a necessity for providing patient-centered, quality care. Utilizing simulation in preparation for service-learning experiences in resource-limited settings appears highly effective for enhancing soft skill development in rehabilitation clinicians; making great strides toward producing culturally compassionate providers.