CONSTRUCTION AND VALIDATION OF A CLINICAL SIMULATION SCENARIO FOR TEACHING CONFLICT MANAGEMENT

ABSTRACT

Objective:

Develop and validate a clinical simulation scenario for undergrad nursing students to learn conflict management.

Method:

Methodological study in which a conflict management scenario was constructed in the city of São Paulo, SP, Brazil, in 2022, based on the literature review and the pedagogical experience of the researchers. Content validation was carried out with judges in the field using the Delphi technique. The data was analyzed with a Content Validity Index (CVI>80%).

Results:

The scenario describes the scene of a nursing trainee asking the nursing technician to bathe a patient in bed. This is permeated by interpersonal conflicts. The content validation involved eight experts in clinical simulation and two nursing students. There were three “rounds,” reaching IVC 100%.

Conclusion:

The scenario was validated and will contribute to the practical teaching of this skill in undergraduate courses.

KEYWORDS:
Nursing Education; Conflict Resolution; Group Processes; Professional Competence; Realistic Simulation.

RESUMO:

Objetivo:

construir e validar um cenário de simulação clínica voltado para o ensino do gerenciamento de conflitos para estudantes de graduação em enfermagem.

Método:

estudo metodológico no qual construiu-se um cenário de gerenciamento de conflitos, na cidade de São Paulo, SP, Brasil, em 2022, a partir da revisão de literatura e da experiência pedagógica dos pesquisadores. Realizou-se validação de conteúdo com juízes da área por meio da técnica Delphi. Os dados foram analisados com Índice de Validade de Conteúdo (IVC>80%).

Resultados:

o cenário descreve a cena de um estagiário de enfermagem que solicita ao técnico de enfermagem realizar um banho no leito de um paciente. Tal fato é permeado por conflitos interpessoais. A validação de conteúdo contou com oito experts em simulação clínica e dois estudantes de enfermagem. Houve três “rounds”, chegando ao IVC 100%.

Conclusão:

o cenário construído foi validado e contribuirá para o ensino prático desta competência na graduação.

DESCRITORES:
Educação em Enfermagem; Resolução de Conflitos; Processos Grupais; Competência Profissional; Simulação Realística.

RESUMEN

Objetivo:

Construir y validar un escenario de simulación clínica destinado a enseñar la gestión de conflictos a estudiantes universitarios de enfermería.

Método:

Estudio metodológico en el que se construyó un escenario de gestión de conflictos en la ciudad de São Paulo, SP, Brasil, en 2022, a partir de la revisión bibliográfica y de la experiencia pedagógica de los investigadores. La validación del contenido se llevó a cabo con jueces sobre el terreno mediante la técnica Delphi. Los datos se analizaron con un Índice de Validez del Contenido (IVC>80%).

Resultados:

el escenario describe la escena de un practicante de enfermería que pide al técnico de enfermería que bañe a un paciente en la cama. Esto está impregnado de conflictos interpersonales. En la validación del contenido participaron ocho expertos en simulación clínica y dos estudiantes de enfermería. Hubo tres rondas, alcanzando el IVC al 100%.

Conclusión:

el escenario fue validado y contribuirá a la enseñanza práctica de esta habilidad en los cursos de licenciatura.

DESCRIPTORES:
Educación en enfermería; Resolución de conflictos; Procesos de grupo; Competencia profesional; Simulación realista.

HIGHLIGHTS

1. Simulation scenario for teaching conflict management.

2. Strategy for teaching management skills.

3. Validation of a simulation scenario for use in an academic environment.

4. Active methodology for teaching and learning conflict management.

HIGHLIGHTS

1. Simulation scenario for teaching conflict management.

2. Strategy for teaching management skills.

3. Validation of a simulation scenario for use in an academic environment.

4. Active methodology for teaching and learning conflict management.

INTRODUCTION

Human relationships are permeated by conflict, whether in the family or professional environment. Nurses need to be competent to manage conflicts, as a disharmonious environment can lead to problems related to self-esteem, poor care, implications for the organizational climate and professional relationships, and damage to the institution’s reputation¹-².

In the training process, developing managerial and interprofessional skills is inherent to good professional practice for nurses. In this context, developing leadership, communication, and teamwork skills is fundamental, so they act strongly to resolve conflicts¹. Some strategies are used for conflict management: 1) avoidance, in which there is little concern for oneself or others; 2) accommodation, in which there is little concern for oneself and high concern for others; 3) domination, in which there is high concern for oneself and low concern for others; 4) conciliation, in which there is a medium level of concern for oneself and others; and 5) integration, in which there is a high level of concern for oneself and others, requiring collaboration between those involved³.

In nursing, conflicts can also be seen from different perspectives. The organizational climate and interpersonal relationships are inevitably affected and shaken if seen as negative. However, regarding the positive aspects, it is an opportunity to learn to discuss procedures, methods, and materials in a given situation. It is often the nurse’s responsibility to make the connection between the conflict and the learning moment, who needs to be assertive when communicating and promoting these moments of exchange between those involved².

As mentioned in the previous paragraph, conflict management in nursing is a complex activity that requires developing knowledge, skills, and attitudes from the early years of the degree. However, there are gaps, as we can see in a study highlighting the need to invest in training this professional in conflict mediation, communication, and interpersonal relationships. In addition, they point out the lack of discussions on the subject with students during their undergraduate nursing studies and the lack of preparation for teachers to take advantage of situations that expose students to conflicts².

Nursing today is expected to explore knowledge in an innovative, dynamic, and collaborative way that brings about change, generating reflections and innovations that promote benefits for users, professionals, and health organizations. In this context, reflective practice promotes the safety and quality of the health services provided and favors the training of critical and committed professionals⁴.

Given this, clinical simulation scenarios aimed at conflict management promote the connection between the theoretical knowledge studied and the practice engaged in attitudinal processes, thus constituting the development of the desired competence. Students learn to recognize conflict, promote open communication, and develop the ability to deal with each person’s differences, having a concrete learning experience and reflecting on their actions⁵.

In a study carried out in 2018, nursing students were given experiences related to learning conflict management through role-playing. After the theatricalization of conflict management, it was possible to notice an improvement in theoretical knowledge. The teaching strategy based on dramatization enables future professionals to develop their ability to deal with conflicts⁵.

Finally, clinical simulation scenarios place students in environments and situations that are very similar to reality, taking them out of their comfort zone and providing them with the thoughts, reflections, and development of skills expected of a good professional⁶. The national curriculum guidelines for undergraduate nursing courses include educational activities that link theory and practice, such as simulation. It is a pedagogical resource aimed at experiential learning, guaranteeing the development of skills and competencies safely, considering that it does not expose participants to avoidable risks. From a clinical perspective, simulation can be understood as an active methodology carried out in a structured, standardized way and based on the literature⁷.

Given the above, this study aimed to build and validate a clinical simulation scenario aimed at teaching conflict management to undergraduate nursing students.

METHOD

This is a methodological study of the construction and validation of a clinical simulation scenario for teaching conflict management to nursing students: 1) Construction of the scenario based on the pedagogical experience of the researchers and a literature search; 2) Validation of the content considering the inclusion and exclusion criteria of the judges, sending of the formal invitation together with the Consent Form as well as the data collection instrument including the scenario evaluation items. 3) Analysis of the answers using the CVI (Content Validity Index).

Initially, a literature review was carried out on the Lilacs, Scielo, and PubMed databases, using the descriptors “Nursing Education”, “Conflict Resolution”, “Group Processes”, “Professional Competence” and “Realistic Simulation”, with the following selection criteria: to address the construction and validation of simulation scenarios, which were available in their entirety, in Portuguese, English, and Spanish, in the last five years. Based on the results, the references used to build and validate the scenario were defined: Manual de Simulação Clínica do Conselho Regional de Enfermagem; Fabri et al; and INACSL Standards Committee⁸-¹⁰.

Considering the data found in the literature and the pedagogical experience of the researchers, the scenario for application with nursing students was constructed. The proposed context centers on the nursing trainee asking a nursing technician on the team to carry out a bed bath. From the moment the task is requested, the environment is permeated by interpersonal conflicts. The scenario aims to assess the student’s theoretical knowledge of conflict management and ability to negotiate and communicate assertively, with emotional intelligence, empathetic listening, a sense of ethics and justice, teamwork, collaboration, unity, and agility in solving problems².

A script was constructed to guide the actor in conducting the simulation scenario, to systematize and organize the simulated environment, and to encourage the participant to meet the proposed objectives. It was separated into stages: theorizing, briefing, the scenario itself, and debriefing.

Theorizing raises awareness of the subject with videos, articles, and pre-selected content that refer to the subject being discussed. Subsequently, the pre-briefing is an agreement between the participants to define who will be active in the scenario and the signing of the confidentiality agreement. Afterward, the briefing is the time to read the scene and what will happen in this simulation, a narrative description of the facts¹¹.

After the execution of the scenario, the debriefing takes place, which is a time to discuss the events to enrich the learning of both the participant and the instructor so that students are guided to reflect on their successes during the simulation and possible points for improvement, and also to participate in the learning process actively. O debriefing must be surrounded by trust and is extremely important for achieving the objectives of the proposed scenario since information is exchanged and assimilated at this time¹².

The Fehring criteria was adapted to define the judges participating in the validation. Fehring criteria, considering their academic background as the main deciding factor. The judges were selected based on their professional profile, and the minimum score to include them in the study was 7, using the following adapted criteria: doctorate in nursing = 4; master’s degree in nursing = 3; dissertation in the area of nursing with a focus on simulation = 2; articles published in one of the areas mentioned = 1; care practice or teaching in one of the areas = 2 and specialization in the area of nursing = 2. This selection was based on the researchers’ CVs, available on the Lattes website of the National Council for Scientific and Technological Development (CNPq)¹³. In addition. However, they did not meet the same selection criteria as the other judges, undergraduate nursing students were also included as judges in the same validation process, given the need to obtain the opinion of the final consumer of the simulated scenario. The inclusion criterion for the students was to be in the last period of the course, with the management curricular unit already taken. Judges who did not meet the above criteria were excluded.

The first stage of data collection was to contact each of the judges selected between April and July 2022 to present the project and send a formal invitation employing a letter of invitation sent by e-mail, together with the Informed Consent Form. After acceptance, the judges individually evaluated the items used in the proposed scenario using a Likert-type scale with five possible answers: agree (5), partially agree (4), neither agree nor disagree (3), partially disagree (2), totally disagree (1)¹⁴ using an electronic form created on Google forms. The rounds were therefore carried out at the same time as the statistical analysis at each stage until consensus was reached.

To validate the scenario, the judges evaluated the items using a Likert scale containing the following items: totally agree, partially agree, neither agree nor disagree, partially disagree, and totally disagree, as well as a specific field for suggestions and adaptations. The Delphi technique was used, which consists of seeking a consensus among the judges on the topic addressed, using questionnaires, to receive feedback systematically. This process was divided into rounds so that, after several opportunities to evaluate, agreement could be reached on the proposed object¹⁵.

The sample was determined using the proportion-based sample calculation formula. The size was calculated using the formula N=Zα². P (1 - P) /e². Where n = sample size; P = proportion of judges (85%); e = margin of error (15%) and Zα = 1.96 (95% confidence), arriving at the number of 18 judges after sample calculation¹⁴.

Descriptive statistics were used, and the degree of agreement with the items was assessed using the Content Validity Index (CVI), which took into account the sum of agreement with the items totally agree (5) and partially agree (4) marked by the judges¹⁴. The formula for evaluating each item was: IVC number of answers 5 or 4 / total number of answers. The items marked neither agree nor disagree (3), partially disagree (2), and totally disagree (1) were checked by the researchers and then sent back to the judges to reach a consensus. The item with an average equal to or greater than 0.80 (80%) was considered desirable in the validation¹⁵.

The study was assessed and approved in 2022 by the Research Ethics Committee (CEP) of the Universidade Federal de São Paulo (UNIFESP) under opinion No. 5.289.966.

RESULTS

At the beginning of April-2022, 18 potential participants who met the selection criteria were invited. Eight judges had already responded fifteen days after the invitation was sent out. After a new call was sent out, two more judges responded to the form, bringing the total number of participants to ten. Among them were six nurses, a biomedical doctor and a medical doctor, all with PhDs, and two final-year undergraduate nursing students.

The first “round had the result as shown in Table 1, based on the Content Validity Index (CVI) of the judges’ responses to the scenario presented.

Table 1
Results of the first round of evaluation of the clinical simulation scenario. São Paulo, SP, Brazil, 2022.

Item		Participants		Agreement		IVC %
Scenario title		10		9		90
General objective of the program				6		60
Target audience				10		100
Learning objectives				8		80
Briefing from the set to everyone				9		90
Briefing from the set to the observers				10		100
Set location				10		100
Time of activities				9		90
A descriptive narrative of the case				9		90
Assertive communication				9		90
Emotional intelligence				9		90
Empathetic listening				9		90
Sense of ethics				9		90
Justice				9		90
Teamwork				9		90
Collaboration				9		90
Union				7		70
Agility in solving problems				9		90
Number of volunteers				9		90
Supporting documents				9		90
Environmental resources				7		70
Bibliographical references				9		90
Scenario script evaluation				8		80
Evaluation of the checklist of the scenario				9,26		92,6
S-CVI						87,6

Source: Authors (2022).

Even though the CVI was > 80%, it was decided to make changes to the proposed scenario, given the relevance of the contributions made by the study participants. To this end, the scenario’s title and the program’s general objective were changed, as there was a need for more specificity. The specific learning objectives have been modified to bring to reality what can be achieved with this scenario; the briefing became unique for both the volunteer (nursing trainee) and the other spectators. This was followed by the pre-simulation stage, which aimed to sensitize the student to the subject. The pre-briefing aimed to recognize the scenario and reduce debriefing time, decreasing the chances of participants dispersing. The debriefing topics were designed to stimulate discussion, reinforce positive points and those that could be improved, and meet the proposed objectives.

From this new scenario, a second “round” was held, and the participants had thirty days to answer the form sent to them. Table 2 shows the results of this new stage.

Table 2
Results of the second round evaluation of the clinical simulation scenario. São Paulo, SP, Brazil, 2022.

Item		Participants		Agreement		IVC %
Scenario title				8		100
General objective of the program		8		6		75
Target audience				8		100
Specific learning objectives				7		88
Briefing of the scenario				7		88
Set location				8		100
Time of activities				6		75
Pre-simulation				8		100
Pre-briefing				8		100
Descriptive narrative of the case				8		100
Number of volunteers				8		100
Supporting documents				8		100
Environmental resources				8		100
Bibliographical references				8		100
Scenario script				8		100
Topics of the debriefing				7,8		98
S-CVI						95

Source: Authors (2022).

In this second “round, eight judges contributed, and two items did not reach the CVI >80%, so there was a need and consistency in accepting the suggestions of the experts, which were to reduce the briefing e pre-briefing to add the information that the nursing technician in the scenario will be an actor and to construct questions to conduct the debriefing if the issues have not been explored. In this sense, a third “round” is needed to align the information with the proposed objective.

In the third and final “round”, seven judges took part, and a CVI of 100% was achieved in all the items evaluated, with suggestions sent in that did not compromise the quality of the scenario, and which could or could not be accepted, according to the experts’ assessment. In this sense, the scenario was considered validated and suitable for undergraduate nursing students, according to the protocol established following the proposed methodology. Chart 1 shows the phases of the simulation scenario and is the result of the validation process:

Chart 1
Clinical simulation scenario for conflict management. São Paulo, SP, Brazil, 2022.

Scenario title	Conflict management in the hospital setting for nursing undergraduates
Target audience	Final-year nursing students at a higher education institution
Learning objectives	Develop conflict management skills through competencies
	Encourage reflection on conflict management
Briefing of the scenario	You’re on duty in the morning during your supervised internship at a medical clinic in a university hospital. Patient João is requesting a bed bath. You must delegate to the nursing technician responsible for this patient that the procedure be carried out. The nursing technician is a highly experienced professional who is about to retire
Set location	University skills laboratory
Pre-simulation	Raising awareness and preparing participants for conflict management: educational video, lecture, reading a book or article, video of a simulated scenario, etc.
Time of activities	Pre briefing e Briefing: 10 minutes
	Scenario: 10 minutes
	Debriefing: 30 minutes
Pre-briefing	Establishing a “fictional contract”, clarifying who the participant will be, and surveying the scenario, seeking to immerse the participants in the simulated scenario. Signing the confidentiality agreement
Descriptive narrative of the case	A nursing trainee from the medical clinic asks the nursing technician to perform a bed bath. This is a professional with a great deal of practical experience, heading towards retirement, with difficulties with communication and teamwork, especially with trainees.
Number of participants	1 volunteer representing the nursing trainee
	1 volunteer representing the nursing technician - standardized participant (actor), a person previously prepared to conduct the scenario to achieve the proposed objectives
Supporting documents	Standardized institutional protocol for the functions and activities to be carried out by each professional in the simulated institution; References presented in class
Environmental resources	λTechnical skills laboratory to set up the simulation scenario; λSignpost: nursing station; λClock on the wall; λMaterials for bed baths; λCamera (if available), to film the simulation and facilitate the debriefing.
Bibliographical references	Conselho Regional de Enfermagem de São Paulo. Manual de Simulação Clínica para profissionais de Enfermagem. São Paulo, SP. 2020. Fabri RP, Mazzo A, Martins JCA, Fonseca A da S, Pedersoli CE, Miranda FBG, et al. Development of a theoretical-practical script for clinical simulation. Revista da Escola de Enfermagem. 2017;51. INACSL Standards Committee. INACSL standards of best practice: SimulationSM Simulation Design. Clinical Simulation in Nursing [Internet]. 2016.
Simulation scenario script
If the trainee asks you to do the bed bath, answer as follows Argue incisively with the trainee if he insists on showering If the trainee wants to show you the institutional protocol, refuse and be firm in your decision not to take the bath If the trainee does not argue and submits to your decision not to perform the bed bath, encourage discussion	I’m not going to do the bed bath because I’m not scheduled to do it, and it’s not fair for me to take over the baths again. Besides, I don’t take orders from trainees. I’ve been here too long to put myself through that. I don’t agree with bathing, because the patients are heavy, I’ve been here for a long time, and the other technicians are doing calmer activities. Pass this activity on to the younger ones. There’s no point in showing me the institutional protocol; after all, nobody follows what’s written there. I’m about to retire and don’t need to put myself through that. I only follow orders from my superiors, not trainees, and the patient doesn’t ask for a bath; we do it when we can. I refuse to do the bath, and if you want, you can call the supervisor. Do you agree that it’s not fair for me to take this bath? I just want justice and support; I feel very overwhelmed.
Debriefing
Summarize the case
How did you feel?
What do you think you’ve done well? How does this relate to practice?
Have you established communication based on respect, clarity, and intercollaboration?
What could have been done differently?
Did you handle the conflict situation properly?
Did you do the right thing without favoring someone because of a personal relationship?
Were you fair, and did you listen to what the coach had to say?
Did you listen to what the coach had to say?
Did you work in a group?
Were you quick to resolve this conflict?
Have you negotiated alternatives and possibilities in the face of conflict?
Given everything you’ve experienced today, what would be important to do if a similar case were to happen?
General observations with a focus on successes.
*The above questions are guiding and do not hinder the expression of the participants; they only guide the debriefing if the issues have not been explored.

Source: Authors (2022).

DISCUSSION

Conflict impacts the quality of patient care and, therefore, needs to be minimized in health services. Coexistence and healthy human relations in the nursing team’s practice environment depend on the nurse’s conflict management quality, who must have adequate training to make this a pleasant environment for employees and patients¹⁶.

A study carried out in 2018 with undergraduate nursing teachers revealed that there is a deficit in teaching focused on management issues in nurse training, keeping the focus of teaching on nursing care. This deficiency in learning this knowledge is perceived at the beginning of the professional career. In this context, the quality of care provided is impacted by weaknesses in developing managerial skills during undergraduate studies. It is related, among other aspects, to the lack of managerial qualifications of the professionals working in the service¹⁷. In this sense, innovative teaching strategies and participatory methodologies such as clinical simulation help to train qualified professionals who are prepared for the demands of the workplace¹⁶.

That said, the study states that it is necessary to move away from the model of transmitting knowledge vertically towards a way that determines knowledge as an exchange between the educator and the student, emphasizing the need for autonomy and co-responsibility of the subject, becoming an active participant in the learning process¹⁸. Education scholars emphasize that students should learn from content that is meaningful to them, i.e., that is part of their social, cultural, and educational universe, present in their daily lives¹⁹.

In a study carried out to identify the gains perceived by students and professionals using clinical simulation with role-playing resources, it was observed that there was an improvement in knowledge, communication, capacity for empathy, development of interpersonal relationships, reduction in stress and anxiety levels, perception of a more favorable environment for the teaching-learning process, as well as greater motivation to try out new learning experiences²⁰.

As far as international literature is concerned, the studies show the same context, in which simulation is inserted as a learning opportunity with better absorption, which brings the student closer to reality and makes this process more enjoyable²¹-²². To this end, in constructing the clinical simulation scenario to develop conflict management skills, national and international manuals on clinical simulation were used to provide schematic scripts to facilitate this process. The scenario must be based on the initial objectives proposed, and the other stages must aim to facilitate and improve the participant’s learning in the simulation scenario²⁰.

When building a clinical simulation scenario, it must be validated to be applied in different environments, situations, and participants. To this end, researchers have used the Delphi technique, which invites judges from the field of simulation or the theme of the scenario, who, in successive rounds, seek consensus among themselves so that no participant has access to the other’s answer. The answers are then analyzed and accepted based on a Content Validity Index (CVI) of 80%. Some studies suggest that between 5 and 12 experts are significant numbers and meet the proposed objective¹³,²³-24.

The method used to select the judges differs between some of the articles found, as is the case of an article to validate a realistic simulation scenario for assessing and treating pressure injuries. The snowball technique was used, in which a judge is invited to participate and indicates others who, in a chain of indications, provide good qualitative and quantitative results of participants for the research¹⁹,²²-²³.

This method can be used in clinical simulation scenarios such as Postpartum Hemorrhage, Pressure Injury assessment and treatment, behavioral situations, and conflict management, the subject of this study¹⁹,²²-²³.

In the first round of the scenario validation process, one of the items that did not obtain the desired CVI was the “general objective of the program”, and for this reason, there was a need for reformulation and adaptation according to the suggestions of the judges and findings in the literature, which address this topic as dependent on the complexity and predetermined time for the execution of the scenario²⁴.

The limitations of this study were the length of time the participants needed to answer the validation instrument and the subjectivity in choosing the relevant contributions to the study. Not having a rubric for the student, contemplating what is expected of them when participating in the scenario, not having a pre-test, and being limited to undergraduate nursing students are also limitations that could be developed in other studies in the future.

CONCLUSION

The scenario was validated and will contribute to the practical teaching of this skill in undergraduate courses, as it will bring students closer to environments similar to the reality they will encounter in their professional practice. In this sense, using simulated scenarios during the undergraduate course corroborates the development of competencies that dialogue with the working environment. When developed during undergraduate studies, managerial skills align with safe and quality care practices, with more harmonious interprofessional relationships and efficient organizations. However, further studies should be conducted to test the scenario’s effectiveness in acquiring knowledge, skills, and attitudes among undergraduate nursing students.

ACKNOWLEDGMENTS

This study was supported by the FAPESP call for proposal 2021/09084-9. We are grateful for their funding.

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Edited by

Associate editor: Dr. Gilberto Tadeu Reis da Silva

Publication Dates

• Publication in this collection
  27 Nov 2023
• Date of issue
  2023

History

• Received
  16 May 2023
• Accepted
  18 Aug 2023