Often in a professional school, be it business, education, law, medicine, nursing, or dentistry, we are faced with the problem of students with little field experience. The difficulty is helping them understand what it is like to operate in that setting. While numerous experiential exercises have been developed to deal with such processes as decision making, communication and influence, frequently such activities involve tasks set in unusual contexts (e.g., "Lost on the Moon," "Desert Survival," or "Star Power"). Consequently, the learner may focus more on the content than on the process of the task, thus hindering the transfer of learning to participants' own work setting. This article describes the development and application of a management simulation exercise used with dental students that incorporates problems from actual dental practice; this methodology, however, could be easily adopted to a variety of situations.
Through interviews with instructors and auxiliary staff, a list of common problem situations was developed along with the specific student, staff and/or patient behaviors which created the difficulty. Problems seemed to be of two general types: structural, i.e., time or task conflicts brought on by emergency patients, cancellations, scheduling errors, etc., and interpersonal difficulties reflecting miscommunication among students, staff and/or patients. Based on these data, patient schedules were constructed for this simulation which included certain structural problems, and scripts were written for dental auxiliaries and patients which introduced both structural and interpersonal problems.
Students are presented with a week's worth of schedules and each student manages the auxiliary staff for one "day." As mentioned above, the schedules contain certain structural errors, for example, a procedure may be scheduled for which insufficient time has been allotted. In addition to schedule errors, interactional and structural dilemmas are introduced by the dental auxiliaries or patients at prearranged times. At the start of that "day," the student briefly inspects the schedule and may recognize certain structural errors and make appropriate adjustments. If not, the simulation progresses until the problem situation is confronted.
The student is paced through the day by a facilitator who announces the time and situation (with the student following on his schedule), e.g., "It is now 10:00 a.m. and both patients have been brought in and seated. You begin treatment A on Mr. Smith while auxiliary Jones starts taking Xrays on Mrs. White." These statements serve as cues to staff and patients for interaction type problems included on their scripts. Thus, Mr. Smith may exhibit severe anxiety about the proposed work or auxiliary Jones may complain about Mrs. White's uncooperativeness. At this point the student must role play the situation and initiate solutions. Once the facilitator is satisfied that the problem has been handled (for better or worse), he moves the student along to the next problem scenario.
40
In addition to scripted problems, the facilitator, staff or patients are free to introduce new problems, particularly those that seem a logical consequence of the student's actions. Thus, a student who manages an overcrowded schedule by detaining certain patients in the waiting area beyond their scheduled appointment time without explanation, is likely to confront several "angry" patients.
At the end of the "day," the student comments on his/her actions and then receives feedback from the facilitator, staff and observing students. After the discussion, a new student assumes the dentist role and the next day of the schedule is run.
The time demands of the simulation depend on the number and types of problems used and the volume of feedback. We have found that with approximately four problems (two structural, two interactional) per day per student, these can be run and debriefed in 1530 minutes. Structural problems are often solved rapidly, particularly if detected early, and most of the time is spent working on interactional issues. With more problems and/or more extensive feedback, the time requirements would expand proportionately.
While, theoretically, there is no limit to the number of scripted roles that can be included, I have found that the complexity of preparing effective scripts increases as a power of the number of roles. Consequently, I have used only five roles in addition to the student's.
We have used students to role play patient roles with limited success. Students tended to pay too much attention to their "lines" and too little attention to the total process, thus limiting their effectiveness in providing feedback. This created difficulties in our situation since only four or five students were used in the simulation sequence (reflecting staff and clinic size limitations). If sufficient observers are available to provide feedback, it seems quite feasible to have participants play all needed roles. Moreover, by having participants play "new" roles (patient, subordinate), they may become sensitized to the issues faced by members of these roles.
The pacing of the day by the facilitator is critical. Since problem episodes are presented in a relatively brieftime frame and the roles of the patients change with the time of day, it is important for the leader to provide adequate transition statements to make the "day" flow smoothly and to keep participants and observers on track with the current action. One successful method has been to briefly summarize the student's actions, indicate the passage of time and lead into the next scenario: "So you'll handle the problem of the emergency patient who showed up unexpectedly by rescheduling Mr. Jones, your 11 o'clock patient, and putting her in that slot. Okay, you get through the rest of the morning without incident. You have just returned from lunch, it is 12:55, the patients are in the waiting area, and the following situation is occurring...."
It should be emphasized that, while the simulation was successful the first time we ran it, we have spent considerble time and energy "fine tuning" the simulation process to make it an exceptionally powerful learning tool. While originally designed for dental students, the simulation exercise could be modified to provide management experience for participants in a variety of settings. While this modification process is a bit more difficult than simply using a design from a handbook, the impact of the exercise would appear to justify the additional effort.