Labor and Delivery Services:You are the new manager of the Social Services Department of a small, 18-bed rural hospital within the Bright Road Health Care System. As a member of the ethics committee f

Health Care Ethics Navigate 2 Scenario : Continuing Obstetric Care at Bright Road December 21 , 2017 Continuing Obstetric Care at Bright Road Introduction: You are the new manager of the Social Services Department of a small, 18 -bed rural hospital within the Bright Road Health Care System. As a member of the ethics committee for the hospital, you have been asked by th e CEO and CFO to contribute to an initial discussion about whether or not to continue having labor and delivery in the hospital. You will speak wi th Board members and hospital staff members to uncover th e hospital, patient, and community impact of such a decision. You will submit your recommendation, along with your rationale, to the committee. Characters: 1. Jeff Passmore, General Counsel for Bright Roads Health Care System 2. Blake Hines , CEO of Bright Road’s Health Care System 3. Kimberly O’Neill , CFO of Bright Road’s Health Care System 4. Ken Bloom, Chief Nursing Officer 5. Sofia Lozano, Concerned citizen Locations: 1. Manager of Social Services’ Office 2. Women’s H ealth Center Conference Room 3. Hospital Corridor 4. General Counsel’s Office 5. CEO’s Office Health Care Ethics Navigate 2 Scenario : Continuing Obstetric Care at Bright Road December 21 , 2017 Scene 1: Meeting Request In this scene, the Social Services Manager is sitting at their desk, checking their calendar and reading email. Location Manager of Social Services’ Office Scene setup The student is looking at the computer On -screen characters None Off -screen characters N/A On -screen text: Let’s see what is on your calendar and then it’s time to check email. Note: A calendar button flashes on screen for student to click. CALENDAR FOR THURSDAY THE 10 TH 1:00 PM: Lunch with Ken Bloom Note: An email button flashes on screen for student to click. EMAIL FROM BLAKE HINES Good morning, As part of the ethics committee, you may know that the administration has been discussing whether or not Bright Road should continue providing labor and delivery services. This is a highly contentious issue due to competing interests, namely the willingne ss and ability of the hospital to continue providing these services in a cost -effective manner weighed against the overwhelming demand by the community. As you know, we are the only hospital in the county to provide these services. If you have time this morning, Kimberly O’Neill and I will be discussing this issue and we’d love to get your input. Are you available at 11 AM? We will be onsite in the large conference room. Best, Blake Blake Hines, Bright Road Health Care System CEO Health Care Ethics Navigate 2 Scenario : Continuing Obstetric Care at Bright Road December 21 , 2017 On -screen text: You’d better respond quickly and go! Note: Email response button flashes on screen for student to click. EMAIL RESPONSE OPTION 1 (CORRECT) Good Morning Blake, Thank you for including me. I will be there. Best, Social Services Manager EMAIL RESPONSE OPTION 2 (INCORRECT) Good Morning Blake, I just read your email and I don’t really have time to come discuss this issue today. But perhaps we should stop providing the service; I don’t think it will have much impact. Talk to you later, Social Services Manager Note: Student choosing option 1 allows student to continue. Selection of Option 2 will trigger response 2 and kick student back to options. On -screen text (RESPONSE 1): Great, you’d better get your things together and don’t forget to take notes at your me eting! On -screen text (RESPONSE 2): That’s not really a productive or constructive way to respond to the CEO’s request. You’d better try again. END OF SCENE 1 Health Care Ethics Navigate 2 Scenario : Continuing Obstetric Care at Bright Road December 21 , 2017 Scene 2: Outlining the Issue In this scene, the student meets with the CEO and CFO to hear th e details of the ethics committee discussion on whether or not Bright Road should continue providing labor and delivery at the rural hospital. Location Women’s Health Center Conference Room Scene setup Blake Hines and Kimberly O’Neill are sitting at the conference room table. On -screen characters Blake Hines, Kimberly O’Neill Off -screen characters N/A On -screen text: You meet with Blake and Kimberly. Be sure you take good notes! Note: Blake and Kimberly are sitting across the table in Bright Road’s Conference Room. BLAKE HINES Thank you for meeting on such short notice. We were just starting to talk about the issue. I know you’re new to our team. Have you met Kimberly O’Neill? STUDENT OPTION 1 Yes. You are Bright Road’s Chief Financial Offi cer, right? KIMBERLY O’NEILL RESPONSE 1 Yes! It’s good to see you. STUDENT OPTION 2 No, I don’t believe so. KIMBERLY O’NEILL RESPONSE 2 I’m KimberlyO’Neill, Bright Road’s Chief Financial Officer. It’s nice to meet you. BLAKE HINES RESPONSE 2 Kim and I were just talking about what kinds of services we currently provide. This hospital has one Ob/Gyn on staff, Dr. Linda Miller who provides labor and delivery services. On -screen text: It’s time to get more information about the hospital’s Ob/Gyn s ervices... Note: Student must choose both options in order to proceed. STUDENT OPTION 1 Do we have a backup Ob/Gyn who can help Dr. Miller out? BLAKE HINES RESPONSE 1 No, we don’t. We have staff that can generally help out in an emergency until Dr. Miller arrives, but none that have her qualifications. Health Care Ethics Navigate 2 Scenario : Continuing Obstetric Care at Bright Road December 21 , 2017 STUDENT OPTION 2 I know that we’re the only hospital in the county. Is there any other Ob/Gyn that provides these services to our community? BLAKE HINES RESPONSE 2 No, unfortunately. We are in a h istorically underserved area and it’s difficult to recruit Ob/Gyn specialists to come out here to practice. Note: Students must choose all options in order to proceed. STUDENT Where’s the next closest hospital that provides labor and delivery services? BLAKE HINES We’re the only hospital in the county. The closest hospital to provide labor and delivery services is about 80 miles away, which is a pretty long drive for someone who’s in labor. Student can choose either option to proceed. STUDENT OPTION 1 It sounds like the community relies on the service. Why are we thinking of discontinuing it? ** STUDENT OPTION 2 So, why would we discontinue the service, when it seems so necessary? KIMBERLY O’NEILL Well, cost quite frankly. Dr. Miller’s malpractice i nsurance increases every year and it’s becoming difficult to keep her here due to her not having backup coverage. BLAKE HINES And women often wait until late in the second trimester or even in the third trimester to start their prenatal care, which can make things more complicated for their doctors. On -screen text: Now, it’s time to talk about alternatives… Note: The student must choose all options in order to proceed. STUDENT OPTION 1 Would Bright Road be willing to hire another Ob/Gyn? KIMBERLY O’NEILL RESPONSE 1 I don’t know how that would be financially possible. As a rural hospital, we tend to run pretty close to cost and don’t have a lot of room in our budget. I suppose the next time we hire, we could look for a physician willing to be the backup for Dr. Miller. Health Care Ethics Navigate 2 Scenario : Continuing Obstetric Care at Bright Road December 21 , 2017 STUDENT OPTION 2 Would our family practitioner be willing to act as the backup for Dr. Miller? KIMBERLY O’NEILL RESPONSE 2 Unfortunately, no. We floated that idea to him but he was reluctant for the same reasons a lot of physici ans don’t go into obstetrics. He doesn’t like unpredictable hours, and doesn’t want to carry the additional insurance. STUDENT Does the community understand the difficulty of finding and keeping an Ob/Gyn on staff? BLAKE HINES Yes, I think that the c ommunity understands and appreciates that we are the only health care provider in the area willing to provide this service. If we stop providing this service, the community will likely be upset. Student can choose either option to proceed. STUDENT OPTION 1 How do you think this decision will affect our relationship with the community? ** STUDENT OPTION 2 Do you think we’ll lose patients? KIMBERLY O’NEILL I don’t think that they’ll start going anywhere else for care because we don’t have any local c ompetition. But it’s tough to predict what people will do. BLAKE HINES Can you talk to Ken Bloom to try and get a read on how he thinks the community would be affected? Student can choose either option to proceed. STUDENT OPTION 1 Yes, of course. ** STUDENT OPTION 2 I’m actually meeting Ken for lunch today. I’ll be sure to bring it up. BLAKE HINES Thanks. Let us know how it goes. END OF SCENE 2 Health Care Ethics Navigate 2 Scenario : Continuing Obstetric Care at Bright Road December 21 , 2017 Scene 3: Impact on Community and Services In this scene, the student talks to K en Bloom in order to assess what the community’s perceptions will be if Bright Road stops providing labor and delivery services, as well as to see if Ken has any suggestions on how to improve these services at the hospital and provide better outcomes. Lo cation Hospital Corridor Scene setup Ken Bloom walks in from the right side of the screen. On -screen characters Ken Bloom Off -screen characters N/A On -screen text: You run into Ken Bloom before your lunch meeting… Note: Start with Hospital Corridor, have Ken walk in from the right side of the screen. KEN BLOOM Hi there, how’s it going. It’s not lunch time yet, is it? Student can choose either option to proceed. STUDENT OPTION 1 Not yet. But while I have your attention, do you have a minute to talk? ** STUDENT OPTION 2 It’s still early. But I do have something I want to discuss. Got a minute? KEN BLOOM Yes, I just finished my rounds and was going to work on some reports. What’s up? Student can choose either option to hear a resp onse, but must choose correct option to proceed. STUDENT OPTION 1 (INCORRECT) The hospital’s ethics committee is trying to assess if it makes sense to Bright Road to continue to provide labor and delivery services. KEN BLOOM RESPONSE 1 Interesting. How can I help? STUDENT OPTION 2 (CORRECT) Bright Road’s ethics committee is trying to assess whether to continue providing labor and delivery services. What are your thoughts? Health Care Ethics Navigate 2 Scenario : Continuing Obstetric Care at Bright Road December 21 , 2017 KEN BLOOM RESPONSE 2 It makes sense to continue providing these services. If we stopped, these patients would have to drive for an hour and a half to get to the nearest hospital! STUDENT Right, I understand that. You work with Dr. Miller occasionally, don’t you? KEN BLOOM I have a few nurses who help with obstetrics. I really d on’t think we can stop providing labor and delivery services. There is no other alternative and our community will not tolerate this service being discontinued. Student can choose either option to proceed. STUDENT OPTION 1 What impression do you get from your nurses about the overall labor and delivery services that we provide? ** STUDENT OPTION 2 What do the nurses think about the labor and delivery services that we provide? KEN BLOOM My nurses are generally happy to be providing a much -needed service to the community. They are also aware that Dr. Miller bears the burden of this service mostly on her own. On -screen text: Now, it’s time to ask about some challenges... Student must choose both options to proceed. STUDENT OPTION 1 What do you think is Dr. Miller’s biggest concern? KEN BLOOM RESPONSE 1 I think one of the biggest concerns is the cost of malpractice insurance for obstetricians. Compared to all other types of malpractice insurance, obstetricians usually have to pay the highest premiums. But I don’t want to speak for Dr. Miller. You’d have to ask her what her main concerns are. STUDENT OPTION 2 What are the most difficult issues with obstetric care? KEN BLOOM RESPONSE 2 When my nurses complain about working in obstetrics, it’s usually about the patients. These patients are very reluctant to get prenatal care before the end of their second trimester for some reason. Without proper prenatal care, complications are more likely to occur. Health Care Ethics Navigate 2 Scenario : Continuing Obstetric Care at Bright Road December 21 , 2017 STUDENT How does prenatal care affect hospital operations? KEN BLOOM That’s a good question. Pati ents who get regular checkups during the first trimester learn a lot about how to prepare for pregnancy, labor, and delivery. If a patient is able to take better care of herself during pregnancy, she is likely to experience fewer complications in labor and delivery. Fewer complications mean lower costs for the hospital and that benefits the community. STUDENT Do you know if we have had many malpractice suits brought against our doctors? KEN BLOOM I don’t think we have. In general, our community isn’t too litigious. But Jeff Passmore, the hospital’s general counsel, is a better person to talk to about that. STUDENT That’s a good idea, I think that I’ll do that. Meet you back here for lunch at 1? KEN BLOOM Sure. See you then! END OF SCENE 3 Health Care Ethics Navigate 2 Scenario : Continuing Obstetric Care at Bright Road December 21 , 2017 Scene 4: Legal Advice After speaking to Ken Bloom, the student decides to talk to Jeff Passmore about the legal implications of continuing to provide delivery and labor services to the community and the community’s history of being reluctant to sue the hospital du e to being grateful that the hospital provides these services. Location General Counsel’s Office Scene setup Jeff Passmore is sitting at his desk On -screen characters Jeff Passmore Off -screen characters N/A On -screen text: You schedule a meeting with Jeff Passmore to get more information about malpractice suits at the hospital … STUDENT OPTION 1 Hi Jeff, thank you for taking the time to meet with me. JEFF PASSMORE Well, how can I help bring you up to speed about malpractice? Student can choose either option to get a response, but must choose the correct option to proceed. STUDENT OPTION 1 (INCORRECT) I’m sitting on the hospital’s ethics committee and we’ve been talking about labor and delivery services here at the hospital. JEFF PASSMO RE RESPONSE 1 Well, I’m not exactly tied too closely to obstetrics… STUDENT OPTION 2 (CORRECT) I was talking to Ken Bloom about labor and delivery services and he said we have a low occurre nce of malpractice suits. Is that right? JEFF PASSMORE RESPONSE 2 Yes. Compared with other hospitals, we fortunately have a low litigation rate. Student can choose either option to get a response, but must choose the correct option to proceed. STUDENT OPTION 1 (INCORRECT) Is it because our patients are too scared to sue us? Health Care Ethics Navigate 2 Scenario : Continuing Obstetric Care at Bright Road December 21 , 2017 JEFF PASSMORE RESPSONSE 1 No, I don’t think that’s the reason. STUDENT OPTION 2 (CORRECT) Is it because our patients value the service we provide to them? JEFF PASSMORE RESPONSE 2 That might be true. It’s difficult to say why different groups would be more likely to sue than others. But the fact that they don’t have an alternative might cause them to be more forgiving on smaller issues. Student can choose either option to get a response, but must choose the correct option to proceed. STUDENT OPTION 1 (CORRECT) Do you think that litigation rates will be affected if we discontinue providing labor and delivery services? JEFF PASSMORE RESPONSE 1 It’s possible. The community probably won’t be happy about Bright Road discontinuing a service like this, but I’m not sure that they’ll take it out on us through increased lawsuits. STUDENT OPTION 2 (INCORRECT) What can we do to keep our patients from suing us? Can we threaten to withdraw from the market to decrease our lit igation rate? JEFF PASSMORE RESPONSE 2 That’s a very unethical action to even suggest, and I used to work in the tobacco industry! STUDENT What does a malpractice case generally cost the hospital? JEFF PASSMORE It depends on where the hospital is and what the state’s regulations are regarding malpractice lawsuits. Some states have passed tort reform legislation to cap the amount of damages that a judge can require a hospital or obstetrician to pay to a patient for pain and suffering. The most common cap is $250,000. In these states, malpractice insurance premiums are much lower than in states where there is no cap. Student can choose either option to proceed. STUDENT OPTION 1 And our state laws don’t have a cap, right? ** STUDENT OPTION 2 If I recall correctly, our state doesn’t have a cap. Health Care Ethics Navigate 2 Scenario : Continuing Obstetric Care at Bright Road December 21 , 2017 JEFF PASSMORE That’s correct, which is why our premiums are so high. They could be as much as 18 times lower if there were a cap in place. Court -awarded payouts could also be a lot higher than $250,000. Student can choose either option to proceed. STUDENT OPTION 1 Wow. That’s pretty high. ** STUDENT OPTION 2 That’s quite a payout! JEFF PASSMORE Definitely. But we might be able to do a few things to lower the risk and decrease our premiums. The easi est thing to do would be to hire an additional Ob/Gyn. Having more than one will reduce Dr. Miller’s workload. If her workload is reduced, the insurance company might reduce her rates because she’s less likely to make a costly mistake. Student can choose either option to proceed. STUDENT OPTION 1 That’s a good point. ** STUDENT OPTION 2 That sounds like a viable solution. JEFF PASSMORE Well, overall, if you’re able to decrease the risk at the hospital in general, then there will be fewer mistakes and fewer malpractice cases brought against the hospital and our staff. Student can choose either option to proceed. STUDENT OPTION 1 That puts it into a new perspective. Thank you for taking some time out of your day to talk to me, this has been ver y informative. ** STUDENT OPTION 2 Thank you for taking some time out of your day to talk to me. I appreciate your point of view. JEFF PASSMORE Any time. Let me know if you need any more help with this issue. END OF SCENE 4 Health Care Ethics Navigate 2 Scenario : Continuing Obstetric Care at Bright Road December 21 , 2017 Scene 5: Touching Base In this scene, the student goes back to their office to check email and to receive an unexpected phone call from Sofia Lozano, a concerned community member. The student also receives an email from Blake Hines requesting a brief meeting in her office. Locatio n Manager of Social Services’ office Scene setup Student is sitting at the computer On -screen characters None Off -screen characters Sofia Lozano On -screen text: It’s time to process what Jeff, Ken, Blake and Kimberly have told you about labor and delivery services at Bright Road… Note: Make the phone button flash for student to click on. On -screen text: Looks like you’re getting a phone call… STUDENT Hello, Brig ht Road Social Services. MS. LOZANO Hello, my name is Sofia Lozano. I heard from a friend of mine who works at your hospital that the hospital is going to stop delivering babies soon. Is this true? Student can choose either option to proceed. STUDENT OP TION 1 Uh… no, not exactly, do you live here in the community? ** STUDENT OPTION 2 Ms. Lozano, are you a member of the community that Bright Road s ervices? MS. LOZANO Well, I am pregnant, but I do n't have insurance. And I know other women in my situation that don’t have the right paperwork to qualify for government programs. STUDENT May I ask, where were you planning to have your baby? MS. LOZANO I don’t really know. There is a clinic where women like me go, because they don’t charge as much and they don’t ask too many questions. STUDENT I see. And you know for a fact that many women use this clinic? Health Care Ethics Navigate 2 Scenario : Continuing Obstetric Care at Bright Road December 21 , 2017 MS. LOZANO Yes, I personally know many families that have their babies at this clinic. We’d prefer to have them at your hospital, but we just don't feel like that's an option . STUDENT There are some non -profit health clinics close by that you might not be aware of. Would you be able to come in to the hospital, so that we can talk further? MS. LOZANO I guess, if you promise that you 'll keep our conversation confidential . STUDENT Yes, I promise. Please come in and we’ll see what we can do for you. I really beli eve we can help you. MS. LOZANO Fine. I’ll come in tomorrow. STUDENT If it’s okay with you, I’d also like to talk to you more about the other women you say are in your same predicament. MS. LOZANO Sure. If there’s a better option for women in my situ ation, then I’d like to share it. STUDENT Great. I’ll see you tomorrow. Take care. MS. LOZANO Goodbye. Note: Make phone end -call button flash for student to click. On -screen text: Well, that was unexpected! Try and think about how this part of the community can be served by Bright Road as you continue to work on the issue of whether or not to continue these services. Oh, looks like you’ve received an email… Note: Make email button flash for student to click on. EMAIL FROM BLAKE HINES Hello, Thanks for meeting with Kimberly and me this morning, I hope that you’ve been giving this issue your direct attention. Can you come by my office to give me an update? Thanks! Blake On -screen text: When Blake wants an issue resolved, she wants the results fast! Looks like you’ll be paying her a visit soon! END OF SCENE 5 Health Care Ethics Navigate 2 Scenario : Continuing Obstetric Care at Bright Road December 21 , 2017 Scene 6: Reviewing the Issues In this scene, the student returns to Blake Hine’s office to discuss the student’s initial thoughts. The student is trying to find a solution that is acceptable fo r all parties concerned and realizes that this will require all parties to compromise. Location CEO’s Office Scene setup Blake Hines sitting at her desk. On -screen characters Blake Hines Off -screen characters N/A We can’t keep our community from suing us, but we can do things to reduce litigation by reducing errors and improving communication about the relationship between health care costs for us and health care costs for them. BLAKE HINES Hello again. Thanks for getting right to work on this iss ue. Student can choose either option to continue. STUDENT OPTION 1 Of course. I’ve received a lot of good information ** STUDENT OPTION 2 Of course. I can bring you up to speed. BLAKE HINES Great! Well, I’ll leave it to you to quickly summarize and walk me through your findings. Where would you like to start? On -screen text: Select who you’d like to talk about first. Note: Student must select all branches. Within each branch, the student must choose the correct response in order to proceed. BRANCH 1 STUDENT My discussion with Jeff Passmore. BLAKE RESPONSE How did that go? STUDENT OPTION 1 (INCORRECT) We discussed the number of malpractice suits the hospital has right now. Health Care Ethics Navigate 2 Scenario : Continuing Obstetric Care at Bright Road December 21 , 2017 BLAKE HINES RESPONSE 1 That’s interesting, but I’m not sure how that helps drive your recommendation. STUDENT OPTION 2 (CORRECT) We discussed cost drivers of malpractice insurance premiums and how we could potentially keep these costs down. BLAKE HINES RESPONSE 2 That’s helpful information. Jeff has a pretty interesting work history and really brings a wide range of experience to the table. He’s usually dead -on with his perception of situations, at least in terms of the legal ramifications of making decisions. BRANCH 2 STUDENT Ken Bloom’s input. BLAKE R ESPONSE I’m sure Ken had good insight. What did he say? STUDENT OPTION 1 (CORRECT) He focused a lot on providing additional help to Dr. Miller in the form of a backup Ob/Gyn to help her. BLAKE HINES RESPONSE 1 I see his point, but it’s going to be difficult to convince our family practitioner to get on board with this. I’m looking forward to hearing your suggestions for reducing costs and attracting another Ob/Gyn specialist. Anything else? STUDENT He also mentioned the high cost of malpractice ins urance and the inherent problem with women delaying the start of their prenatal care. BLAKE HINES RESPONSE That’s definitely an important factor in the equation. STUDENT OPTION 2 (INCORRECT) He focused on how to avoid malpractice suits. BLAKE RESPONS E 2 Really? I thought he would focus on operations. BRANCH 3 STUDENT The impact on the community. BLAKE HINES RESPONSE The community? Do they even know about this? STUDENT OPTION 1 (INCORRECT) Yes. The information leaked. Health Care Ethics Navigate 2 Scenario : Continuing Obstetric Care at Bright Road December 21 , 2017 BLAKE HINES RESPONSE 1 It usually does. So what are they saying? STUDENT OPTION 2 (CORRECT) I got a call from a community member. She’s not a legal citizen and is worried about traveling to a metropolitan hospital. BLAKE HINES RESPONSE 2 I’m excited to hear the details about y our conversation, but I’m also a bit concerned about how we’re going to negotiate our own legal requirements in this situation. I’m not against it, I think that we should be able to treat everyone in our community. This is just a difficult population to se rve and we’ll need to think about this some more. Student can choose either option to proceed. STUDENT OPTION 1 What have you and Kimberly discussed? ** STUDENT OPTION 2 What do you and Kimberly think? BLAKE HINES We both value your opinion, and are looking for your recommendation. You have my word that your input will be considered very seriously. Student can choose either option to proceed. STUDENT Ok, I’m going to need some time to gather my thoughts and organize a response. ** STUDENT Can I h ave a little bit of time before I get this to you? BLAKE HINES Yes, of course. I don’t expect you to provide an answer on the spot. But don’t take too long; this is an important issue! I look forward to your recommendation. END OF SCENE 6 Health Care Ethics Navigate 2 Scenario : Continuing Obstetric Care at Bright Road December 21 , 2017 Assessment If all previous scenes have been completed, a 10 -question assessment is presented to the student. Answer the following 10 questions to show what you know about health care ethics for labor and delivery. Good luck! The student answers the ques tions and then sees the assessment results. Assessment Results Here are your results. Click Continue if you are satisfied with the result. Or you can click Try Again if you want to try and improve your score. NOTE: The student can retry the assessment by clicking the Try Again button, or can continue to final scene by clicking the Continue button. Health Care Ethics Navigate 2 Scenario : Continuing Obstetric Care at Bright Road December 21 , 2017 Scene 7: Making Your Recommendation In this scene, the student will craft an email to Blake Hines, Kimberly O’Neill and Jeff Passmore at Bright Road, with a re commendation. The recommendation will consider both sides of the issue based on information gathered from the staff and community members. Location Social Services Manager’s Office Scene setup Student is sitting in front of the computer On -screen charac ters None Off -screen characters None On -screen text: After gathering information from key team members, it’s time to make a decision. NOTE: The scene is a close up of the student’s computer screen with the email application open. The “To:” section is filled with email addresses of Blake Hines, Jeff Passmore, and Kimberly O’Neill and the subject is already filled in: “CONFIDENTIAL: Labor and Delivery Services at Bright Road.” On -screen text: Type your recommendation in the body of the email below. Don’t forget, you can use the notes you’ve taken throughout your interviews. Be sure to back up your decision with the analysis of the information gained from the team members, and input from the community member. Click Send when you are ready to submit your re commendation. NOTE: The student will be given an option to “ Send" (s ubmit ) the email after writing it. On -screen text: Congratulations! Your recommendation has been sent! FADE OUT NOTE: The student will be given an option View/Save their recommendation bef ore closing the scenario . THE END