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Virtual Antenatal Encounter and Standardized Simulation Assessment (VANESSA): Pilot Study

Virtual Antenatal Encounter and Standardized Simulation Assessment (VANESSA): Pilot Study Background: Prenatal counseling at the limits of newborn viability involves sensitive interactions between neonatal providers and families. Empathetic discussions are currently learned through practice in times of high stress. Decision aids may help improve provider communication but have not been universally adopted. Virtual standardized patients are increasingly recognized as a modality for education, but prenatal counseling simulations have not been described. To be valuable as a tool, a virtual patient would need to accurately portray emotions and elicit a realistic response from the provider. Objective: To determine if neonatal providers can accurately identify a standardized virtual prenatal patient’s emotional states and examine the frequency of empathic responses to statements made by the patient. Methods: A panel of Neonatologists, Simulation Specialists, and Ethicists developed a dialogue and identified empathic responses. Virtual Antenatal Encounter and Standardized Simulation Assessment (VANESSA), a screen-based simulation of a woman at 23 weeks gestation, was capable of displaying anger, fear, sadness, and happiness through animations. Twenty-four neonatal providers, including a subgroup with an ethics interest, were asked to identify VANESSA’s emotions 28 times, respond to statements, and answer open-ended questions. The emotions were displayed in different formats: without dialogue, with text dialogue, and with audio dialogue. Participants completed a post-encounter survey describing demographics and experience. Data were reported using descriptive statistics. Qualitative data from open ended questions (eg, “What would you do?”) were examined using thematic analysis. Results: Half of our participants had over 10 years of clinical experience. Most participants reported using medical research (18/23, 78%) and mortality calculators (17/23, 74%). Only the ethics-interested subgroup (10/23, 43%) listed counseling literature (7/10, 70%). Of 672 attempts, participants accurately identified VANESSA’s emotions 77.8% (523/672) of the time, and most (14/23, 61%) reported that they were confident in identifying these emotions. The ethics interest group was more likely to choose empathic responses (P=.002). Participants rated VANESSA as easy to use (22/23, 96%) and reported that she had realistic dialogue (15/23, 65%). Conclusions: This pilot study shows that a prenatal counseling simulation is feasible and can yield useful data on prenatal counseling communication. Our participants showed a high rate of emotion recognition and empathy in their responses. (JMIR Serious Games 2018;6(2):e8) doi: 10.2196/games.9611 KEYWORDS prenatal counseling; simulation; ethics http://games.jmir.org/2018/2/e8/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e8 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Motz et al Examine differences in participants’ responses to questions Introduction posed by the virtual patient. One out of every ten babies is born prematurely [1]. It has Methods become standard practice for health care providers to offer expectant mothers with premature labor a prenatal consultation. This observational study was approved by the Seattle Children’s This prenatal consultation addresses the complications of Hospital Institutional Review Board. All attending premature birth and gives parents a chance to engage in a Neonatologists, Neonatal-Perinatal medicine fellows, and NNPs dialogue about what to expect for their baby. The prenatal from the University of Washington and Seattle Children's consultation becomes even more critical when babies are very Hospital were eligible to participate, and all Neonatologists who premature and may be born at the limits of medical capacity to attended a biweekly neonatal ethics interest group participated. successfully provide life-sustaining care, otherwise known as Providers who did not routinely provide perinatal counseling the limits of viability [2]. Families may make life or death were excluded. decisions based on the information given to them by their health care provider. Prior studies show that most parents wish to VANESSA, a prototype virtual standardized perinatal patient participate in decision-making in these kinds of situations [3]. of a woman pregnant at 23 weeks gestation, was adapted from However, parents often cannot recall the therapeutic options a medical history-taking virtual patient simulator [8] with that are discussed or find that their decision-making is not animated emotional responses on the Unity 3D platform [9]. impacted by physicians’ predictions of survival and outcomes The VANESSA simulator was programmed to display the [3]. Rather, psychosocial influences such as religion, spirituality, emotions of anger, fear, happiness, and sadness through and hopefulness more readily guided their decisions [2]. In some animations of facial expressions and body language. An SP case cases, up to a quarter of parents prefer to relinquish decision and potential responses were developed with input from making autonomy, either to physicians or by leaving the attending Neonatologists who provided extensive perinatal situation in “God's hands” [2,4]. counseling services (Table 1). Using the VANESSA interface with the potential patient responses programmed, the scenario Despite the gravity of these conversations, there is evidence was deployed to participants [10]. A structured dialogue of the that communication during prenatal consultations could be scenario was programmed to include the full potential range of significantly improved, and there have also been calls for a more emotions. Potential responses to VANESSA’s dialogue were standardized approach to perinatal counseling [4]. For example, developed with each set containing both empathic and some researchers have proposed a framework with visual aids nonempathic options. Demographic data and feedback on the to help parents better understand the outcomes of babies born product were collected using an online survey [11]. at the limit of viability [5]. However, this approach of providing more standardized information does not always meet the needs Participants were emailed a link to the online module and of parents. Parents need to feel understood and supported as associated survey. First, participants were shown video clips of they advocate for their baby in a collaborative and VANESSA displaying emotions with no dialogue (out of compassionate environment [3]. context) and asked to identify the emotion she was expressing. Participants were then taken through the prenatal counseling Over the last two decades, the use of standardized patients (SPs) scenario with text displays of both patient and provider dialogue for health provider communication training has increased [4]. (in context with text) and asked to identify the emotions (Figure However, their use in prenatal counseling is limited and there 1). is evidence that even with training, SP encounters are prone to recall bias that may lead to inconsistent feedback [6]. Virtual The online module ended with participants participating in the SPs may be a more accessible and cost-effective approach. counseling with opportunities to choose responses to the However, in these emotionally charged conversations, the ability patient’s statements. The interactive counseling section provided of the virtual patient to project a recognizable emotion is a key audio from the SP and text-based responses to move the scenario element to creating a valid user experience [7]. We hypothesize forward. Participants were again asked to identify VANESSA’s that a standardized virtual patient simulator called Virtual emotions during the case (in context with audio). The Antenatal Encounter and Standardized Simulation Assessment concordance between the displayed emotion and participant (VANESSA), with the capacity to express emotions, will be a responses was determined for each context. At the end of the feasible approach to developing health care provider encounter, participants were asked two open-ended questions communication skills in prenatal counseling. by the simulator: (1) “What would you do?” and (2) “What are my options?” Participants responded by typing into a text box. We set out to achieve the following objectives: There was no limit to the length of the participant responses. Enhance a virtual SP simulator with animations reflecting Once the scenario was finished, the participants filled out a four primary emotional states. post-encounter survey that included demographic information, Evaluate the degree to which practicing Neonatologists and years of experience, and formal training in counseling or neonatal nurse practitioners (NNPs) can correctly identify perinatal counseling. The survey elicited participants’ the virtual SP’s emotional states and the frequency of impressions of the usability of the simulator using a 5-point empathic responses to statements made by the patient. Likert scale (from 1=strongly agree to 5=strongly disagree). http://games.jmir.org/2018/2/e8/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e8 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Motz et al Table 1. Excerpt of VANESSA dialogue. Topic Sample Dialogue Animation Introduction Dr. X: Hi, I’m the neonatal provider on-call. Your obstetrician asked me to meet with Happy you to discuss your baby with you. VANESSA: Hi, thank you for coming. Assessing patient’s comfort/ interest in talking Dr. X: Is this an okay time to talk? Sad VANESSA: My husband is gone for the day, but I can talk now. (Patient anima- tion—Sad) Assess current understanding Dr. X: What is your understanding of what might happen in the next few days? Afraid VANESSA: It sounds like the baby is coming. I’m only six months along. (Patient animation—Afraid) Relationship building Dr. X: Have you picked a name for the baby? Happy VANESSA: I’m going to call him Robert, after my dad. Dr. X: That’s a great name. (Patient animation—Happy) Figure 1. VANESSA prototype interface. the data. Individual codes were discussed further and collapsed Statistical Analyses into major themes. The final themes were reached after thorough Demographic information was analyzed with summary statistics. discussion from the two readers. A third study team member Multiple choice responses to statements made by VANESSA (MG) was consulted for discrepancies. were collected and analyzed by subgroups including gender, clinical experience, job title, counseling resources used, previous Results perinatal counseling training, and ethics research focus. Statistical analyses included Kruskal-Wallis and Mann-Whitney Participant Demographics tests to evaluate various study subgroups, as the data did not A total of 24 neonatal providers participated in the pilot study follow a normal distribution. A P value <.05 was considered (Table 2). The group was evenly divided between those with significant. Responses to the open-ended questions were less than 10 years of neonatal clinical experience and those with analyzed using a grounded theory analysis approach. Two study more than 10 years of experience. Most participants reported team members (PM and RU) evaluated the open-ended using medical research and mortality calculators as resources responses. An initial list of codes was identified by analyzing for their perinatal counseling (Table 2). Only the group of http://games.jmir.org/2018/2/e8/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e8 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Motz et al Neonatologists who attended a biweekly neonatal ethics interest emotions but were less accurate at identifying the sad (63.8%, group listed counseling literature as a resource. Didactic lectures 134/210) emotion. on perinatal counseling and perinatal counseling simulation use Empathic Response to VANESSA were infrequently utilized as resources by participants in this Participants chose empathic responses to VANESSA 75.0% study. Most participants had been previously trained via clinical (81/108) of the time. The response chosen most often was, “I observation. No participants felt that VANESSA was can see this is upsetting.” The nonempathic response most often unnecessarily complex and 96% (22/23) felt they could use chosen was, “I have more information to share with you, may VANESSA without the support of a technical person. Few I go on?” This response accounted for 81% (22/27) of all the respondents (3/23, 13%) disagreed with the statement that nonempathic choices. VANESSA was realistic and only one participant felt that she did not respond as other patients would. The group of Neonatologists who attended a biweekly neonatal ethics interest group were more likely to choose empathic Emotional Identification responses (P=.01) but were not more likely than the other groups Of the 672 emotions presented, participants accurately identified to correctly recognize VANESSA’s emotions. We also assessed VANESSA’s emotion 78.9% (530/672) of the time. As expected, differences based on gender, clinical experience, job title, giving participants context through text and audio dialogue did counseling resources used, and counseling training. There were improve their accuracy of emotional identification (Figure 2). no statistically significant differences between these groups. When given no contextual dialogue participants were fairly accurate at 74.4% (192/258). By adding text dialogue, Qualitative Analysis of Participant Responses respondents improved to 81.7% (291/356) when the context The qualitative analysis of the two open-ended questions of, was given. Participants’ confidence in how accurate they were “What would you do?” and, “What are my options?” posed by at identifying emotions lagged slightly behind their actual VANESSA yielded over 50 codes. The codes were distilled into accuracy (Figure 3). When analyzed by each emotion, we found four themes: eliciting the mother’s values, sharing the that participants were easily able to identify happy (89.8%, counselor’s values, this is a difficult choice, and the desire to 219/244), afraid (78.0%, 192/246), and angry (80.5%, 161/200) give more information to aid the decision. Table 2. Demographics of study participants. Demographics n (%) Gender Male 8 (35) Female 16 (65) Profession Neonatal nurse practitioner 7 (29) Physician 17 (71) Clinical experience >10 years 12 (50) <10 years 12 (50) Previous counseling training Clinical observation 23 (96) Workshop 4 (17) Simulation 9 (38) Communication workshop 6 (25) Resources used for perinatal counseling Medical research 18 (78) Counseling literature 7 (30) Lectures 5 (22) Simulation 3 (13) Mortality calculator 17 (74) http://games.jmir.org/2018/2/e8/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e8 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Motz et al Figure 2. Accuracy of emotion recognition versus participants’ impression of accurate emotional recognition. Figure 3. Participants’ empathic versus nonempathic responses. http://games.jmir.org/2018/2/e8/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e8 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Motz et al Participants focused on eliciting the mother's values: noted similar accuracy levels for happiness, afraid, sadness, and angry using photographic images of facial expressions of Let's talk more about how you're feeling so I can help emotion [14]. you to [the] best answer for your family. It is important for health care providers to accurately perceive There is no right or “expert” answer, but I am here emotions to provide the appropriate support and empathy for to help you consider what is best for your baby given patients who are struggling with a diagnosis or those who are your values and unique situation. coping with a loss. The responses of a subgroup of participants Sharing the counselor's values was demonstrated through who attended a biweekly neonatal ethics interest group were statements such as: significantly more empathic toward VANESSA. This finding Like you, I would want the best for my baby; whatever is consistent with counseling literature that shows that health that might be. care providers with interest in ethics had more empathy toward their patients and demonstrates that counseling approaches I would want to make a decision together with my employed with virtual SPs may parallel those of actual partner. Is there any way for your husband to come encounters [4]. be with you? Participants also acknowledged the difficult nature of the Virtual prenatal counseling training may be valuable to medical decision and recognized that there were different approaches: and advanced practice provider training programs. A survey of neonatology program directors revealed an interest in This decision is difficult and overwhelming. Everyone standardizing prenatal counseling training [6]. A prenatal approaches these life challenges differently with counseling simulator could be used for just-in-time training for different priorities. residents and fellows and could serve as a way for experienced Few participants gave the definite answer not to resuscitate the health care providers to get feedback on their prenatal soon-to-be-born baby when asked, “What would you do?” Some counseling. participants expressed that they didn’t know what they would Our qualitative analysis of participant responses to VANESSA's do if they were in that situation: open-ended questions yielded several themes related to the I don't know. I've seen very loving families do different health care providers’ approaches when faced with a difficult things. question. Most of our participants did attempt to elicit the Many participants offered more information: mother's values rather than presenting their own, but fewer acknowledged that this was a difficult decision with uncertainty I want to give you as much information as I can, so in the outcome. Review of the literature notes that families find you and your family can make the decision that is the these two themes to be very important in their counseling [15]. best for you. We think this issue underlines the need for further improvement Others reflected the question back to VANESSA in an attempt in how we communicate with our patients and underscores the to elicit her goals and values: value of virtual SP simulators in research on prenatal counseling, which will be a focus in the next phase of VANESSA's Tell me what is important for your baby and your development. family. Limitations Discussion The limitations of our study were that it was conducted at a Principal Findings single academic center and it had a small sample size. Some strengths of our study are that our participants were Our study findings demonstrated the feasibility and potential representative of a large academic neonatology practice, our utility of an emotionally expressive virtual perinatal counseling participants were evenly split between highly experienced simulator. The “happy,” “afraid,” and “angry” emotions were providers and moderately experienced providers, and we had identified with an accuracy of 80% to 90% (192/246 to 219/244). participation from both NNPs and physicians. A high level of emotion recognition by participants interacting with a female virtual SP in a simulated prenatal counseling Conclusions session is encouraging and is consistent with previous studies In conclusion, this pilot study shows that a perinatal counseling that show that recognition of emotion is most accurate on female simulation is feasible and can yield useful data on perinatal faces [7,12]. The “sad” emotion was identified accurately only counseling communication. Our participants showed a high rate 63.8% (134/210) of the time. This discrepancy persisted despite of emotion recognition and empathy in their responses. Further providing additional text or audio context through scripted work needs to be done to develop our prototype further but conversations. It is possible that the intensity of the “sad” demonstrating the recognition of VANESSA’s emotions has emotion animation was not adequate or that it may have been laid a solid foundation for additional research to validate this perceived by participants as a blend of emotions when only one approach. forced choice response was available [13]. Previous studies Conflicts of Interest None declared. http://games.jmir.org/2018/2/e8/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e8 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Motz et al References 1. Frey H, Klebanoff N. The epidemiology, etiology, and costs of preterm birth. Semin Fetal Neonatal Med 2016 Apr;21(2):68-73. [doi: 10.1016/j.siny.2015.12.011] [Medline: 26794420] 2. Payot A, Gendron S, Lefebvre F, Doucet H. Deciding to resuscitate extremely premature babies: how do parents and neonatologists engage in the decision? Soc Sci Med 2007 Apr;64(7):1487-1500. 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How to systematically assess serious games applied to health care. JMIR Serious Games 2014 Nov 11;2(2):e11 [FREE Full text] [doi: 10.2196/games.3825] [Medline: 25654163] Abbreviations NNP: neonatal nurse practitioner SP: standardized patient VANESSA: Virtual Antenatal Encounter and Standardized Simulation Assessment Edited by G Eysenbach; submitted 08.12.17; peer-reviewed by S Perry, T Antunes; comments to author 20.01.18; revised version received 05.03.18; accepted 07.03.18; published 11.05.18 Please cite as: Motz P, Gray M, Sawyer T, Kett J, Danforth D, Maicher K, Umoren R JMIR Serious Games 2018;6(2):e8 URL: http://games.jmir.org/2018/2/e8/ doi: 10.2196/games.9611 PMID: 29752249 ©Patrick Motz, Megan Gray, Taylor Sawyer, Jennifer Kett, Douglas Danforth, Kellen Maicher, Rachel Umoren. Originally published in JMIR Serious Games (http://games.jmir.org), 11.05.2018. 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Virtual Antenatal Encounter and Standardized Simulation Assessment (VANESSA): Pilot Study

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Abstract

Background: Prenatal counseling at the limits of newborn viability involves sensitive interactions between neonatal providers and families. Empathetic discussions are currently learned through practice in times of high stress. Decision aids may help improve provider communication but have not been universally adopted. Virtual standardized patients are increasingly recognized as a modality for education, but prenatal counseling simulations have not been described. To be valuable as a tool, a virtual patient would need to accurately portray emotions and elicit a realistic response from the provider. Objective: To determine if neonatal providers can accurately identify a standardized virtual prenatal patient’s emotional states and examine the frequency of empathic responses to statements made by the patient. Methods: A panel of Neonatologists, Simulation Specialists, and Ethicists developed a dialogue and identified empathic responses. Virtual Antenatal Encounter and Standardized Simulation Assessment (VANESSA), a screen-based simulation of a woman at 23 weeks gestation, was capable of displaying anger, fear, sadness, and happiness through animations. Twenty-four neonatal providers, including a subgroup with an ethics interest, were asked to identify VANESSA’s emotions 28 times, respond to statements, and answer open-ended questions. The emotions were displayed in different formats: without dialogue, with text dialogue, and with audio dialogue. Participants completed a post-encounter survey describing demographics and experience. Data were reported using descriptive statistics. Qualitative data from open ended questions (eg, “What would you do?”) were examined using thematic analysis. Results: Half of our participants had over 10 years of clinical experience. Most participants reported using medical research (18/23, 78%) and mortality calculators (17/23, 74%). Only the ethics-interested subgroup (10/23, 43%) listed counseling literature (7/10, 70%). Of 672 attempts, participants accurately identified VANESSA’s emotions 77.8% (523/672) of the time, and most (14/23, 61%) reported that they were confident in identifying these emotions. The ethics interest group was more likely to choose empathic responses (P=.002). Participants rated VANESSA as easy to use (22/23, 96%) and reported that she had realistic dialogue (15/23, 65%). Conclusions: This pilot study shows that a prenatal counseling simulation is feasible and can yield useful data on prenatal counseling communication. Our participants showed a high rate of emotion recognition and empathy in their responses. (JMIR Serious Games 2018;6(2):e8) doi: 10.2196/games.9611 KEYWORDS prenatal counseling; simulation; ethics http://games.jmir.org/2018/2/e8/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e8 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Motz et al Examine differences in participants’ responses to questions Introduction posed by the virtual patient. One out of every ten babies is born prematurely [1]. It has Methods become standard practice for health care providers to offer expectant mothers with premature labor a prenatal consultation. This observational study was approved by the Seattle Children’s This prenatal consultation addresses the complications of Hospital Institutional Review Board. All attending premature birth and gives parents a chance to engage in a Neonatologists, Neonatal-Perinatal medicine fellows, and NNPs dialogue about what to expect for their baby. The prenatal from the University of Washington and Seattle Children's consultation becomes even more critical when babies are very Hospital were eligible to participate, and all Neonatologists who premature and may be born at the limits of medical capacity to attended a biweekly neonatal ethics interest group participated. successfully provide life-sustaining care, otherwise known as Providers who did not routinely provide perinatal counseling the limits of viability [2]. Families may make life or death were excluded. decisions based on the information given to them by their health care provider. Prior studies show that most parents wish to VANESSA, a prototype virtual standardized perinatal patient participate in decision-making in these kinds of situations [3]. of a woman pregnant at 23 weeks gestation, was adapted from However, parents often cannot recall the therapeutic options a medical history-taking virtual patient simulator [8] with that are discussed or find that their decision-making is not animated emotional responses on the Unity 3D platform [9]. impacted by physicians’ predictions of survival and outcomes The VANESSA simulator was programmed to display the [3]. Rather, psychosocial influences such as religion, spirituality, emotions of anger, fear, happiness, and sadness through and hopefulness more readily guided their decisions [2]. In some animations of facial expressions and body language. An SP case cases, up to a quarter of parents prefer to relinquish decision and potential responses were developed with input from making autonomy, either to physicians or by leaving the attending Neonatologists who provided extensive perinatal situation in “God's hands” [2,4]. counseling services (Table 1). Using the VANESSA interface with the potential patient responses programmed, the scenario Despite the gravity of these conversations, there is evidence was deployed to participants [10]. A structured dialogue of the that communication during prenatal consultations could be scenario was programmed to include the full potential range of significantly improved, and there have also been calls for a more emotions. Potential responses to VANESSA’s dialogue were standardized approach to perinatal counseling [4]. For example, developed with each set containing both empathic and some researchers have proposed a framework with visual aids nonempathic options. Demographic data and feedback on the to help parents better understand the outcomes of babies born product were collected using an online survey [11]. at the limit of viability [5]. However, this approach of providing more standardized information does not always meet the needs Participants were emailed a link to the online module and of parents. Parents need to feel understood and supported as associated survey. First, participants were shown video clips of they advocate for their baby in a collaborative and VANESSA displaying emotions with no dialogue (out of compassionate environment [3]. context) and asked to identify the emotion she was expressing. Participants were then taken through the prenatal counseling Over the last two decades, the use of standardized patients (SPs) scenario with text displays of both patient and provider dialogue for health provider communication training has increased [4]. (in context with text) and asked to identify the emotions (Figure However, their use in prenatal counseling is limited and there 1). is evidence that even with training, SP encounters are prone to recall bias that may lead to inconsistent feedback [6]. Virtual The online module ended with participants participating in the SPs may be a more accessible and cost-effective approach. counseling with opportunities to choose responses to the However, in these emotionally charged conversations, the ability patient’s statements. The interactive counseling section provided of the virtual patient to project a recognizable emotion is a key audio from the SP and text-based responses to move the scenario element to creating a valid user experience [7]. We hypothesize forward. Participants were again asked to identify VANESSA’s that a standardized virtual patient simulator called Virtual emotions during the case (in context with audio). The Antenatal Encounter and Standardized Simulation Assessment concordance between the displayed emotion and participant (VANESSA), with the capacity to express emotions, will be a responses was determined for each context. At the end of the feasible approach to developing health care provider encounter, participants were asked two open-ended questions communication skills in prenatal counseling. by the simulator: (1) “What would you do?” and (2) “What are my options?” Participants responded by typing into a text box. We set out to achieve the following objectives: There was no limit to the length of the participant responses. Enhance a virtual SP simulator with animations reflecting Once the scenario was finished, the participants filled out a four primary emotional states. post-encounter survey that included demographic information, Evaluate the degree to which practicing Neonatologists and years of experience, and formal training in counseling or neonatal nurse practitioners (NNPs) can correctly identify perinatal counseling. The survey elicited participants’ the virtual SP’s emotional states and the frequency of impressions of the usability of the simulator using a 5-point empathic responses to statements made by the patient. Likert scale (from 1=strongly agree to 5=strongly disagree). http://games.jmir.org/2018/2/e8/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e8 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Motz et al Table 1. Excerpt of VANESSA dialogue. Topic Sample Dialogue Animation Introduction Dr. X: Hi, I’m the neonatal provider on-call. Your obstetrician asked me to meet with Happy you to discuss your baby with you. VANESSA: Hi, thank you for coming. Assessing patient’s comfort/ interest in talking Dr. X: Is this an okay time to talk? Sad VANESSA: My husband is gone for the day, but I can talk now. (Patient anima- tion—Sad) Assess current understanding Dr. X: What is your understanding of what might happen in the next few days? Afraid VANESSA: It sounds like the baby is coming. I’m only six months along. (Patient animation—Afraid) Relationship building Dr. X: Have you picked a name for the baby? Happy VANESSA: I’m going to call him Robert, after my dad. Dr. X: That’s a great name. (Patient animation—Happy) Figure 1. VANESSA prototype interface. the data. Individual codes were discussed further and collapsed Statistical Analyses into major themes. The final themes were reached after thorough Demographic information was analyzed with summary statistics. discussion from the two readers. A third study team member Multiple choice responses to statements made by VANESSA (MG) was consulted for discrepancies. were collected and analyzed by subgroups including gender, clinical experience, job title, counseling resources used, previous Results perinatal counseling training, and ethics research focus. Statistical analyses included Kruskal-Wallis and Mann-Whitney Participant Demographics tests to evaluate various study subgroups, as the data did not A total of 24 neonatal providers participated in the pilot study follow a normal distribution. A P value <.05 was considered (Table 2). The group was evenly divided between those with significant. Responses to the open-ended questions were less than 10 years of neonatal clinical experience and those with analyzed using a grounded theory analysis approach. Two study more than 10 years of experience. Most participants reported team members (PM and RU) evaluated the open-ended using medical research and mortality calculators as resources responses. An initial list of codes was identified by analyzing for their perinatal counseling (Table 2). Only the group of http://games.jmir.org/2018/2/e8/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e8 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Motz et al Neonatologists who attended a biweekly neonatal ethics interest emotions but were less accurate at identifying the sad (63.8%, group listed counseling literature as a resource. Didactic lectures 134/210) emotion. on perinatal counseling and perinatal counseling simulation use Empathic Response to VANESSA were infrequently utilized as resources by participants in this Participants chose empathic responses to VANESSA 75.0% study. Most participants had been previously trained via clinical (81/108) of the time. The response chosen most often was, “I observation. No participants felt that VANESSA was can see this is upsetting.” The nonempathic response most often unnecessarily complex and 96% (22/23) felt they could use chosen was, “I have more information to share with you, may VANESSA without the support of a technical person. Few I go on?” This response accounted for 81% (22/27) of all the respondents (3/23, 13%) disagreed with the statement that nonempathic choices. VANESSA was realistic and only one participant felt that she did not respond as other patients would. The group of Neonatologists who attended a biweekly neonatal ethics interest group were more likely to choose empathic Emotional Identification responses (P=.01) but were not more likely than the other groups Of the 672 emotions presented, participants accurately identified to correctly recognize VANESSA’s emotions. We also assessed VANESSA’s emotion 78.9% (530/672) of the time. As expected, differences based on gender, clinical experience, job title, giving participants context through text and audio dialogue did counseling resources used, and counseling training. There were improve their accuracy of emotional identification (Figure 2). no statistically significant differences between these groups. When given no contextual dialogue participants were fairly accurate at 74.4% (192/258). By adding text dialogue, Qualitative Analysis of Participant Responses respondents improved to 81.7% (291/356) when the context The qualitative analysis of the two open-ended questions of, was given. Participants’ confidence in how accurate they were “What would you do?” and, “What are my options?” posed by at identifying emotions lagged slightly behind their actual VANESSA yielded over 50 codes. The codes were distilled into accuracy (Figure 3). When analyzed by each emotion, we found four themes: eliciting the mother’s values, sharing the that participants were easily able to identify happy (89.8%, counselor’s values, this is a difficult choice, and the desire to 219/244), afraid (78.0%, 192/246), and angry (80.5%, 161/200) give more information to aid the decision. Table 2. Demographics of study participants. Demographics n (%) Gender Male 8 (35) Female 16 (65) Profession Neonatal nurse practitioner 7 (29) Physician 17 (71) Clinical experience >10 years 12 (50) <10 years 12 (50) Previous counseling training Clinical observation 23 (96) Workshop 4 (17) Simulation 9 (38) Communication workshop 6 (25) Resources used for perinatal counseling Medical research 18 (78) Counseling literature 7 (30) Lectures 5 (22) Simulation 3 (13) Mortality calculator 17 (74) http://games.jmir.org/2018/2/e8/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e8 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Motz et al Figure 2. Accuracy of emotion recognition versus participants’ impression of accurate emotional recognition. Figure 3. Participants’ empathic versus nonempathic responses. http://games.jmir.org/2018/2/e8/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e8 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Motz et al Participants focused on eliciting the mother's values: noted similar accuracy levels for happiness, afraid, sadness, and angry using photographic images of facial expressions of Let's talk more about how you're feeling so I can help emotion [14]. you to [the] best answer for your family. It is important for health care providers to accurately perceive There is no right or “expert” answer, but I am here emotions to provide the appropriate support and empathy for to help you consider what is best for your baby given patients who are struggling with a diagnosis or those who are your values and unique situation. coping with a loss. The responses of a subgroup of participants Sharing the counselor's values was demonstrated through who attended a biweekly neonatal ethics interest group were statements such as: significantly more empathic toward VANESSA. This finding Like you, I would want the best for my baby; whatever is consistent with counseling literature that shows that health that might be. care providers with interest in ethics had more empathy toward their patients and demonstrates that counseling approaches I would want to make a decision together with my employed with virtual SPs may parallel those of actual partner. Is there any way for your husband to come encounters [4]. be with you? Participants also acknowledged the difficult nature of the Virtual prenatal counseling training may be valuable to medical decision and recognized that there were different approaches: and advanced practice provider training programs. A survey of neonatology program directors revealed an interest in This decision is difficult and overwhelming. Everyone standardizing prenatal counseling training [6]. A prenatal approaches these life challenges differently with counseling simulator could be used for just-in-time training for different priorities. residents and fellows and could serve as a way for experienced Few participants gave the definite answer not to resuscitate the health care providers to get feedback on their prenatal soon-to-be-born baby when asked, “What would you do?” Some counseling. participants expressed that they didn’t know what they would Our qualitative analysis of participant responses to VANESSA's do if they were in that situation: open-ended questions yielded several themes related to the I don't know. I've seen very loving families do different health care providers’ approaches when faced with a difficult things. question. Most of our participants did attempt to elicit the Many participants offered more information: mother's values rather than presenting their own, but fewer acknowledged that this was a difficult decision with uncertainty I want to give you as much information as I can, so in the outcome. Review of the literature notes that families find you and your family can make the decision that is the these two themes to be very important in their counseling [15]. best for you. We think this issue underlines the need for further improvement Others reflected the question back to VANESSA in an attempt in how we communicate with our patients and underscores the to elicit her goals and values: value of virtual SP simulators in research on prenatal counseling, which will be a focus in the next phase of VANESSA's Tell me what is important for your baby and your development. family. Limitations Discussion The limitations of our study were that it was conducted at a Principal Findings single academic center and it had a small sample size. Some strengths of our study are that our participants were Our study findings demonstrated the feasibility and potential representative of a large academic neonatology practice, our utility of an emotionally expressive virtual perinatal counseling participants were evenly split between highly experienced simulator. The “happy,” “afraid,” and “angry” emotions were providers and moderately experienced providers, and we had identified with an accuracy of 80% to 90% (192/246 to 219/244). participation from both NNPs and physicians. A high level of emotion recognition by participants interacting with a female virtual SP in a simulated prenatal counseling Conclusions session is encouraging and is consistent with previous studies In conclusion, this pilot study shows that a perinatal counseling that show that recognition of emotion is most accurate on female simulation is feasible and can yield useful data on perinatal faces [7,12]. The “sad” emotion was identified accurately only counseling communication. Our participants showed a high rate 63.8% (134/210) of the time. This discrepancy persisted despite of emotion recognition and empathy in their responses. Further providing additional text or audio context through scripted work needs to be done to develop our prototype further but conversations. It is possible that the intensity of the “sad” demonstrating the recognition of VANESSA’s emotions has emotion animation was not adequate or that it may have been laid a solid foundation for additional research to validate this perceived by participants as a blend of emotions when only one approach. forced choice response was available [13]. Previous studies Conflicts of Interest None declared. http://games.jmir.org/2018/2/e8/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e8 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Motz et al References 1. Frey H, Klebanoff N. The epidemiology, etiology, and costs of preterm birth. Semin Fetal Neonatal Med 2016 Apr;21(2):68-73. [doi: 10.1016/j.siny.2015.12.011] [Medline: 26794420] 2. Payot A, Gendron S, Lefebvre F, Doucet H. Deciding to resuscitate extremely premature babies: how do parents and neonatologists engage in the decision? Soc Sci Med 2007 Apr;64(7):1487-1500. 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How to systematically assess serious games applied to health care. JMIR Serious Games 2014 Nov 11;2(2):e11 [FREE Full text] [doi: 10.2196/games.3825] [Medline: 25654163] Abbreviations NNP: neonatal nurse practitioner SP: standardized patient VANESSA: Virtual Antenatal Encounter and Standardized Simulation Assessment Edited by G Eysenbach; submitted 08.12.17; peer-reviewed by S Perry, T Antunes; comments to author 20.01.18; revised version received 05.03.18; accepted 07.03.18; published 11.05.18 Please cite as: Motz P, Gray M, Sawyer T, Kett J, Danforth D, Maicher K, Umoren R JMIR Serious Games 2018;6(2):e8 URL: http://games.jmir.org/2018/2/e8/ doi: 10.2196/games.9611 PMID: 29752249 ©Patrick Motz, Megan Gray, Taylor Sawyer, Jennifer Kett, Douglas Danforth, Kellen Maicher, Rachel Umoren. Originally published in JMIR Serious Games (http://games.jmir.org), 11.05.2018. 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Published: May 11, 2018

Keywords: prenatal counseling; simulation; ethics

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