Nurses routinely perform intimate care when they assist patients in showering, bathing, toileting, managing incontinence aids or dressing chronic or surgical wounds located in personal body regions (for example, the genitalia or breast). Examples of wounds include simulated pressure injuries, burns, pilonidal sinuses, fistulas, surgical wounds and chronic ulcers (Figure 1).
As recipients of intimate care, patients can be at their most vulnerable. For experienced nurses, providing intimate care may be routine; however, the same cannot be said for neophyte nursing students. The thought of providing personal invasive care, for example touching a patient's ‘private parts’, can create feelings of distress, apprehension or even repulsion (Montgomery, 2014; O'Lynn and Krautscheid, 2014; Mainey et al, 2018; Reid-Searl et al, 2019). Nursing students need to be prepared to deliver intimate care, not only for the patient, but also to reduce fear and anxiety and gain confidence for themselves (Reid-Searl et al, 2019).
For students, the preparation should begin in the classroom or laboratory of their tertiary educational setting, where the context provides a safety net. The preparation should take place prior to students undertaking clinical placements at a healthcare facility (Reid-Searl and O'Neill 2017; Mainey et al, 2018; Reid-Searl et al, 2019). For many nursing students, the preparation for this type of care is practised on manikins or task trainers. These simulation modalities lack the realism of true human responses and, therefore, the nuances of intimate care skills are left until the student is managing a patient in the healthcare facility.
Background
As a nurse educator, I grew increasingly concerned. To address the lack of realism in the context of the clinical laboratory, I decided to teach intimate care using a different approach, one that would require me to wear silicone props in the form of a face mask and body suit.
The idea to use props occurred after having been with a group of first-year nursing students who were tasked with managing a pressure-injury wound located on the buttocks of a task trainer. I watched students attend to the dressing observing the principles of aseptic technique; however, they lacked dialogue, in terms of explaining what was happening for the patient and how that person might be feeling. This led me to ask the students to take a break and come back into the class after 30 minutes. During this time, I donned a wig, glasses and nightware and attached the task trainer to myself to transform into a patient with a wound. Students returned to the classroom and were then briefed by a co-teacher to apply the dressing on me, disguised as a simulated patient.
I soon realised that I was not a typical simulated patient; rather, I was the teacher in a role, hidden beneath the props. I advised students that I was a retired nurse and gave them tips to guide them in undertaking the dressing. As the students attended to my wound, they also began to engage with me as a patient, showing respect and regard. At the same time, I also realised that some students were reluctant to touch me or to be close. This, I would later identify after the debrief, was because they still saw my face as their teacher. I was their assessor, and a power differential existed.
Reflecting on this teaching episode, I identified the need to remove myself visually from the learners by masking to be the hidden educator. Furthermore, behind the character facade, I could guide students in nursing care. I could also move into zones that could facilitate students to consider empathy, communication and ultimately address their challenges around intimate care.
I pondered over the ways I could remove myself visually from the learners. I first attempted to use hard plastic face masks. These were not effective, as they were not pliable. The solution of using silicone masks came about after watching Robin Williams play the title role in Mrs Doubtfire. With the support of mask makers in the US, I set about purchasing a face mask and later co-designed a wearable silicone torso with genitalia so that students could attend to hygiene and elimination care. The props were highly realistic, enabling my total transformation into the character of an older person (Figure 2). The character would have a backstory that reflected knowledge and wisdom and so could coach the students in the classroom, particularly on skills relating to intimate care.
After implementing this masked approach in a first-year foundations of nursing course, student feedback was positive, as evidenced by unsolicited oral feedback, emails and course evaluations over a three-term period. This positive feedback was later confirmed in findings from research that focused on student experiences using Mask-Ed (Reid-Searl et al, 2011; 2012).
Interest also grew from academic peers and industry clinicians. I then began to analyse what I was doing and articulate a framework that could guide others in implementing the same technique. I would ultimately describe the approach as Mask-Ed (KRS Simulation). Mask-Ed can be defined as a highly realistic simulation technique whereby an informed educator transforms into a character by donning silicone props and assuming a history and backstory, enabling them to become the platform for learning and teaching (Reid-Searl et al, 2011; 2012).
Fundamentals
The acronym in KRS Simulation stands for knowledgeable, realistic and spontaneous. ‘Knowledgeable’ describes the educator's understanding of the objectives of the session, the content being imparted and the strategies needed to engage the learners (McAllister et al, 2013). ‘Realistic’ describes the realism of the character, including their backstory, their mannerisms and the authenticity of the story being disseminated. The reality hinges on the experience of the educator, who should have a deep understanding of their discipline and the simulation experience. ‘Spontaneous’ describes how the reaction of the character should be unprompted, and how there are no set scripts. However, the character is directed by the educator, who is, in-turn, influenced by the learner's response. Because scripts are not set, reactions to learners can be immediate (Reid-Searl et al, 2011; 2012).
There are three essential elements of Mask-Ed: the character, the coach and the context. The character is central to the technique and is the person into whom the educator transforms into once they don the silicone props. The character should be warm, friendly and a gift in the classroom, as well as always vulnerable. The character expects respect for their knowledge and passes information to the learner. Designing the character takes time and requires the educator to be skilled in the use of voice, mannerisms and traits to depict who they are playing. The character is also built around curriculum requirements to best suit the needs of learners. Without preparation to develop the character, the technique can be ineffective, and, instead of emerging as a coach, the hidden educator can fall into the role of a simulated patient and not deliver wisdom to the learner. Educators who use Mask-Ed undertake 2 days of training in order to build the character and play the role.
The coach represents the hidden teacher being channelled through the character to facilitate the learning. Unlike standard teachers, the coach in Mask-Ed does not assess the learner or ask questions; rather, they are the givers of information. They take the ‘t’ out of can't to encourage the learners to believe they can. The coach is a difficult role to perform in this technique, because it is easy to assume the part of a simulated patient, without the teacher emerging through the character. Research confirms that thorough preparation is required, and, without adequate training, there is risk that the technique is lost (Reid-Searl et al, 2014).
The final C is the context, and this is about the situation and the setting in which the simulation occurs. To create realism, the surroundings need to be real and the character needs to be suitably dressed, and consistent with the character they are portraying.
Although various studies report that Mask-Ed is highly realistic (Kable et al, 2018), provides students with positive learning experiences (Reid-Searl et al, 2011; 2012) and requires careful training and preparation (Reid-Searl et al, 2014), it is in the area of intimate care that Mask-Ed presents a new direction (Reid-Searl and O'Neill, 2017; Reid-Searl et al, 2019).
Mask-Ed provides an opportunity for students to prepare for intimate care where the context of the classroom or laboratory provides a safety net. The props allow the character to be revealed physically and emotionally. The torso props allow the breasts and genitalia of the character to be exposed to the students. This exposure enables students to see the vulnerability of the character. When students are exposed to this type of experience, they report feeling that they are dealing with a real person and are thus more prepared for their clinical placement (Reid-Searl and O'Neill, 2017). Reid-Searl and O'Neill (2017) identified that first-year nursing students increased their confidence to deliver intimate care after participating in a Mask-Ed care scenario involving the toileting and showering of an elderly Mask-Ed character during their on-campus learning. This was explored further by Reid-Searl et al (2019), who identified that, after participating in a similar scenario, first-year nursing students learned to overcome their nervousness and anxiety, discovered the vulnerable person at the centre of their care, gained confidence and felt prepared for their clinical placement, where they dealt with patients requiring intimate care.
The use of Mask-Ed has the potential to expand in the space of teaching intimate care for neophyte nursing students. However, further research and evaluation is required to understand the experience of educators in using these props and the responses of learners. With such data, guidelines can be further developed to promote safe practice in the wider dissemination of this approach.
Conclusion
Mask-Ed (KRS Simulation) is a highly realistic simulation approach. This carefully constructed technique centres around the educator donning highly realistic silicone props and transforming into another person. The newly created person then becomes the platform for learning and teaching. The character is designed to create human connection to coach and empower learners. The vulnerability of the character puts learners into situations where they feel comfortable with providing intimate human care.
Limitations
There are several limitations for Mask-Ed. Its success stems from the human being behind the silicon props. As a type of simulation, it is not quickly or easily scalable, and the success of each session depends heavily on variable factors, such as the skill of the educator, the robustness of the character's background story and the clarity of the boundary between educator and character. Preparation through the correct educational channels is essential. This is particularly apt when educators are using the technique to simulate intimate care episodes. Furthermore, wearing the masks can be challenging for some individuals, and it is best to limit the duration of time they are worn. Infection control is highly important, and thorough cleaning of the props between users is essential.