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Observer roles that optimise learning in healthcare simulation education: a systematic review

Observer roles that optimise learning in healthcare simulation education: a systematic review Background: Simulation is widely used in health professional education. The convention that learners are actively involved may limit access to this educational method. The aim of this paper is to review the evidence for learning methods that employ directed observation as an alternative to hands-on participation in scenario-based simulation training. We sought studies that included either direct comparison of the learning outcomes of observers with those of active participants or identified factors important for the engagement of observers in simulation. We systematically searched health and education databases and reviewed journals and bibliographies for studies investigating or referring to observer roles in simulation using mannequins, simulated patients or role play simulations. A quality framework was used to rate the studies. Methods: We sought studies that included either direct comparison of the learning outcomes of observers with those of active participants or identified factors important for the engagement of observers in simulation. We systematically searched health and education databases and reviewed journals and bibliographies for studies investigating or referring to observer roles in simulation using mannequins, simulated patients or role play simulations. A quality framework was used to rate the studies. Results: Nine studies met the inclusion criteria. Five studies suggest learning outcomes in observer roles are as good or better than hands-on roles in simulation. Four studies document learner satisfaction in observer roles. Five studies used a tool to guide observers. Eight studies involved observers in the debrief. Learning and satisfaction in observer roles is closely associated with observer tools, learner engagement, role clarity and contribution to the debrief. Learners that valued observer roles described them as affording an overarching view, examination of details from a distance, and meaningful feedback during the debrief. Learners who did not value observer roles described them as passive, or boring when compared to hands-on engagement in the simulation encounter. Conclusions: Learning outcomes and role satisfaction for observers is improved through learner engagement and the use of observer tools. The value that students attach to observer roles appear contingent on role clarity, use of observer tools, and inclusion of observers’ perspectives in the debrief. Keywords: Simulation, Observer, Observer role, Directed observer, Vicarious learning * Correspondence: saoregan@msn.com Sydney Clinical Skills and Simulation Centre, Royal North Shore Hospital, Level 6 Kolling Building, Reserve Rd, St Leonards, NSW 2065, Australia Full list of author information is available at the end of the article © 2016 O’Regan et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. O’Regan et al. Advances in Simulation (2016) 1:4 Page 2 of 10 Background Methods There has not been a systematic review of the factors The search was conducted over five databases (Medline, that promote learning in the observer roles in simula- Cinahl, PsycINFO, EmBase and ERIC) within a publica- tion. As more learners are allocated to observer roles tion period of 1980 – July 2015 using 45 search terms there is an imperative to ensure that learning in this role and restricted to the English language. Hand searching is optimised. This review seeks to synthesise the factors of grey literature, journal contents and reference lists that focus the observers’ learning and satisfaction in the was also undertaken. The study population included any role and provide educators with guidance to employing healthcare professional or student who participated in observer roles within their simulations. mannequin, simulated patient (actor) or role-play based Simulation is an effective healthcare teaching strategy simulations that included a specific observer role (Table 1). [1] and can improve knowledge, skills and behaviours Studies selected included either direct comparison of the when compared to traditional or no teaching [2]. Simu- learning outcomes of observers with those of active partic- lation conventionally enables learners to physically par- ipants following the simulation or identified the factors ticipate in realistic scenarios replicating real world important for the engagement of observers in simulations practice and has been reported as an effective replace- and needed to identify their outcome measures and in- ment for clinical hours for nursing students [3]. Increas- clude changes in knowledge, skills, attitudes or behaviours ing demand, cohort numbers and access limitations, of participants (Table 2) Specific exclusions included com- particularly in professional entry programs has resulted puter or virtual reality based simulations as the observer in innovative approaches for learners using simulation. role was difficult to define, and specific task or skill train- These approaches include role modelling [4, 5], peer and ing as the teaching methodology is different than case near-peer assisted learning [6–8], and alternative based scenarios. Video based learning and expert role instructional design methods whereby learners are actively directed to observe without hands-on participa- Table 1 Search terms tion [9–11]. We refer to this as the directed observer. Population Intervention Outcome When simulation is used appropriately, it improves Nurs* or Simulation or Learn* or learning outcomes [2, 12]. However, the evidence midwif* or Patient simulation or Knowledge or supporting learning by observation is less clear. Medic* or Manikin* or Skill* or This review presents evidence supporting directed ob- servation as an educational method and features of this doctor or Mannequin* or Attitude* or method that lead to positive educational outcomes. surgery or Simulated patient* or Behav* The literature is not always clear on what constitutes Allied health or Standardised patient* or observer roles. Here, observer roles are defined as two Physiotherap* or Standardized patient* or broad types. First, roles where the learner is external to Occupational therap* or Role play or the simulation. For example, the learner will be watching Dental or Actor or but not participating in the simulation, either within the simulation area or from an area removed from the simu- Dentist* or Acting or lation. Second, roles where the learner is given a role in Social work* or theatre the simulation that is not congruent with their profes- Respiratory therap* or sional one. For example, a nursing student could realis- Dietet* or AND tically be expected to perform the roles of medication Paramedic* or Observ* or nurse, bedside nurse or documentation nurse in their Aboriginal torres strait Observ* role or professional activities. However, they would not be a doctor, social worker or patient relative. In this paper, islander health or Observational learn* or we describe these roles as ‘in-scenario’ observer roles. Fur- Indigen* or Vicarious learn* or ther, observers are described as having a ‘directed obser- Inter professional or Watching ver’ role or a ‘non-directed’ role. A directed observer role Interprofessional or would include a specific instructional briefing or use of an Intra professional or observer tool. A non-directed observer watches without Intraprofessional or specific guidance or objectives. The instructional briefing or observer tool contains information for the directed Multi disciplin* or observer on specific learning objectives, behaviours or Multidisciplin* or activities to consider, points for peer feedback or a check- Multi profession* or list to measure against. These specifics would then form Multiprofession* part of the debrief. O’Regan et al. Advances in Simulation (2016) 1:4 Page 3 of 10 Table 2 Inclusion and exclusion criteria Inclusion/Exclusion Criteria Criterion Inclusion Exclusion Population Clinicians and students of any health profession Non health professionals Intervention Undergoing a mannequin or simulated patient based Computer based, skill or part-task trainers, virtual reality, or cadaveric learning experience and simulation/simulators. � Examines the role of the observer � Studies which do not explicitly examine the observer role. � Has an observer role defined as a learner within a scenario � Observers who are not participating in the learning, for example not in a clinically congruent role or observers for the purpose of research study. � Has an observer role external to scenario participant roles � Expert modelling for learning Outcome measures � A direct or indirect change in knowledge, skills, attitudes � Description of behaviours without consideration of any changes or behaviours in learner behaviour Citations Peer reviewed papers in the english language from 1980 to � Non peer reviewed publications e.g thesis or reports th October 4 2014. � Descriptive papers � Published texts or books modelling were also excluded, as there is no comparison of hands-on and observer roles (Table 2). Results Nine studies were selected from the 5469 potential papers identified using the PRISMA process [13] (Fig. 1). The studies are summarised in Table 3. The included studies used quantitative, qualitative and mixed methods. A modi- fied version of Buckley’s quality indicators, devised for assessment of quantitative, qualitative and mixed methods studies was selected as the quality assessment tool [14]. These 11 quality indicators relate to the appropriateness of study design, conduct, results analysis and conclusions and are not biased towards any particular research meth- odology (Table 4). Two reviewers (SO, EM) rated the quality of the stud- ies with an inter-rater agreement of 0.94 across 99 data points. Seven studies meeting seven or more criteria as specified by Buckley, were considered high quality stud- ies [14]. There was a wide range of quality with scores from 3 to 11 out of a possible 11. Most common prob- lems encountered were with data completeness, control for confounders, study replicability and addressing ethical issues. Two studies, Stegmann [15] and Thidemann, [16] met all 11 criteria. Two studies, Lau [17] and Stiefel, [18] met six or less criteria. Rater differences are shown in the table as two scores, with the lowest total score reported where there was a discrepancy (Table 4). To provide composite data the nine included studies were examined using categories adapted from Cook et al [2]. There were a total of 1203 participants across the nine studies with the majority of studies focusing on undergraduate students in nursing (n = 527) and medi- cine (n = 484). There was one interprofessional study in- volving practising clinicians across four disciplines [19]. Five studies used mannequin-based simulations [11, 16, Fig. 1 Search flow diagram using the PRISMA process 20–22], two employed simulated patients [15, 18], one O’Regan et al. Advances in Simulation (2016) 1:4 Page 4 of 10 Table 3 Summary of selected studies Reference Research paradigm, design & Participants Intervention Learner Observation Style Results sampling Bell, Pascucci, Fancy, Mixed methods Health professionals from Use of improvisational actors in Non-directed role: no use of No difference between observers Coleman, Zurakowski and four disciplines (n =192) difficult conversations to teach observational tool or verbal and hands on learners in: Meyer [24] communication and relational guidance reported perceived realism; usefulness of Post-simulation survey design Teaching faculty (n = 33) skills to practicing health actors; usefulness of scenarios; with qualitative and quantitative professional and, opinions on non-actor role analysis play Convenience sample Actors (SP) (n = 10) Hands on participants (47 %) Observers (53 %) Harder, Ross and Paul [25] Ethnographic stud Bachelor of Nursing Role assignment within regular Non-directed role: no use of Students preferred assignment to students year 3 (n = 84) simulation session with analysis of observer tool or verbal nursing roles rather than observer experience and perceptions of guidance reported or non nursing role learning within different role Observational design with Participant/observation All participants experienced both Structured role descriptions focused interview and journal (n = 84) interview (n = 12) roles positively affected learning review of selected participants outcomes Volunteer sample journal review (n =4) Hober and Bonnel [11] Qualitative Bachelor of Nursing “senior” Immersive simulation scenarios Directed observer role: Observer role beneficial, less students (n = 50) with students randomly assigned observer tool – educator stressful to active or observer roles provided activity guidelines Survey and interview design Observers (n = 23) All completed survey Use of a guided observer tool useful Convenience sample hands on learners (n = 27) Observers interviewed Able to reflect in action and on action Kaplan, Abraham and Gary [27] Quantitative Bachelor of Nursing “junior” Immersive simulation scenarios - Directed observer role: No difference in knowledge students (n = 92) observer tool -checklist Randomised groups Observers (n = 46) participants self selected roles Convenience sample Scenario participants Unclear whether observers self Limited as aggregated post (n = 46) selected or were assigned satisfaction survey data Post scenario knowledge test and satisfaction survey Lau, Stewart and Fielding [22] Quasi experimental Medical students (bilingual) Student role plays with Directed observer role: Observers rated post knowledge randomised to roles year 1 (n = 160) comparison of learning between observer tool -checklist higher than learners in interpreter interpreter role play and observer role-play role Convenience sample Self rated pre & post knowledge O’Regan et al. Advances in Simulation (2016) 1:4 Page 5 of 10 Table 3 Summary of selected studies (Continued) Smith, Klaassen, Zimmerman Mixed methods with Bachelor of Nursing “junior” Introduction of simulation year 1 Non-directed role: no use of No significant difference in and Cheng [26] increasing variables over three students observational tool or verbal learning outcomes, student Introduction non nursing years guidance reported perceptions or peer evaluations participatory roles year Convenience sample year 1 (n = 67) Introduction non participatory observer roles year 3 year 2 (n =72) year 3 (n =85) Note only the year 2 and 3 data were included in review Stegmann, Pilz, Siebeck and Quantitative Medical students (n = 200) Comparison of participatory role Non-directed and directed Observational learning (especially Fischer [20] and observer role in simulated observer roles compared: if supported by observer script) Crossover design 2x2x2 patient scenario with and without checklists and feedback scripts more effective than learning by pre-test post-test observation tool used doing Stiefel, Bourquin, Layat, Quantitative Medical students (masters Individual training with simulated Non-directed role: no use of Measured outcomes no difference Vadot, Bonvin and Berney level) (n = 124) patient encounter observer tool or verbal [23] guidance reported Randomised into 2 group Individual training (n = 49) Group training with simulated Those who observed but did not Group training (n = 75) patient encounter participate felt they did not meet -participated in simulation their learning objectives as well Evaluation using instructor Group training with observation (n = 14) observed (n =61) compared to the other 2 groups rating scale and student of simulated encounter questionnaire Convenience sample Thidemann and Soderhamn Quasi experimental Bachelor of Nursing student Immersive mannequin simulation Directed observer role: Post-test scores higher in all [21] year 2 (n =144) with random allocation to groups observer tool with specific task groups independent of rol focus Pre - and post-simulation Four volunteers within each More satisfaction with nurse role knowledge test and student group allocated to participatory questionnaire and in scenario observer roles – remainder observers (n = 72) Convenience sample over two consecutive years as attributed by author where available O’Regan et al. Advances in Simulation (2016) 1:4 Page 6 of 10 Table 4 Study ratings using Buckley's (modified) criteria Criteria (Yes, No, Unclear) Bell Harder Hober Kaplan Lau Smith Stegmann Stiefel Thidemann Note: rater disagreement shown as two scores Clear research question U Y Y Y U Y Y U Y Subject group appropriate for study Y Y Y Y Y Y Y Y Y Reliable and valid methods (qualitative or quantitative) used Y Y Y Y Y/U Y Y Y Y Completeness of data (drop out, questionnaire response rate >60 %, YY Y Y N N Y N Y attrition rate <50 %) Controlled for confounders or acknowledged if non RCT design N U/N N U/N U N Y U Y Statistical and other analysis methods appropriate Y Y Y Y Y Y Y Y Y Data justifies the conclusions drawn Y Y Y Y N Y Y U/N Y Study could be replicated Y/U Y Y Y U N/U Y Y Y Prospective study Y Y Y Y Y Y Y Y Y Relevant ethical issues addressed U Y Y N U Y Y U Y Triangulation of data Y Y Y Y N Y Y N Y Total Score/11 (lowest score reported) 7 10 10 9 3 8 11 5 11 an actor [19], and one study involved role-play by the valued the hands-on roles higher did not employ an ob- participant group [17] (Table 5). server tool for the observer group [18]. The observer Eight of the nine studies compared knowledge, skills, tools included performance checklists [15, 17, 22], feed- attitudes or behaviours between the hands-on role and back or observation guides [11, 15], or observer role in- the observer role [11, 15, 17, 18, 20–22]. Six studies used structional briefing [16]. All studies except Bell [23] a pre and post-test design, three of which were self- documented including observers in the post simulation assessment of improvement in knowledge and/or skills debrief or feedback. [17–19] and three studies tested knowledge [15, 16, 21]. Two studies examined knowledge in a post-test only Discussion design [22] one of which was a self-assessment [20]. We sought reported factors that contribute to the opti- Outcomes included knowledge (six), ‘non-technical skills’ misation of learning in the observer role. It is clear from (eight), technical skills (three), attitudes (two) and behav- this review that the use of observer tools to focus the iours (one). observer and role clarity are strongly associated with Four studies found no difference in outcomes between role satisfaction and learning outcomes in observer roles. the hands-on learners and the observers [11, 16, 19, 22]. This finding is supported by Bandura’s social learning Two studies reported superior outcomes in the hands- theory and Kolb’s experiential learning cycle and we on group [18, 20] and one study reported better out- propose that these form the basis of the directed obser- comes in the observer group [15]. The study that found ver role. superior outcomes for the observer group and three of One of the outstanding findings from this review is the four studies that found no difference in outcomes the association of observer tools with both satisfaction between the hands-on and observer groups [15–17, 22] and equal if not better, learning outcomes in observer incorporated an observer tool to guide the observer roles. The use of these tools may move observers from group. Neither study that demonstrated superior out- simply watching to actively observing. The activation of comes by the hands-on learners employed an observer observers allows those in that role to experience the sat- tool [18, 20]. isfaction and learning normally associated with hands- Six studies considered the perceived value of the on experience. Simulation is described by Dieckmann et hands-on learner and observer roles to the participants. al as a social practice where people interact with each Two studies reported that participants valued the hands- other in a goal orientated fashion [24]. The observer tool on roles more than the observer role [18, 20], one study provides this necessary goal orientation for observer highly valued the observer role [16] and three studies re- roles. Directed observers are focused on the learning ob- ported no difference in the value of the roles [11, 19, jectives of the simulation. 22]. Two of the three studies with no value difference in This is explained by Bandura’s social learning theory, roles [11, 22], and the study that valued the observer which proposes that virtually all learning acquired ex- role highly [16] used an observer tool. The study that perientially could also be acquired on “a vicarious basis O’Regan et al. Advances in Simulation (2016) 1:4 Page 7 of 10 Table 5 Characteristics of included studies through observation of other people’s behaviour and its consequences for them” [25]. Through observation Study Characteristics Number of Number of Studies Participants learners can build behaviours without trial and error, ex- All studies 9 1203 perience emotions by watching others and resolve fears through other’s experience. Bandura describes this as a Study participants process of attention, retention, reproduction and motiv- Medical students 3 484 ation [25]. Bethards reports on a program where “simu- Nursing students 5 527 lation experiences are designed around the observer role Practicing clinicians 1 using the four component processes of Bandura’s observa- Physician 43 tional learning construct” [26]. They postulate that this Nurse 114 provides all their learners, regardless of role, the same opportunities to achieve the learning objectives [26]. “Psychosocial clinicians” 20 Vicarious learning requires active listening, reflective Medical interpreter 14 thinking and situational engagement [27]. Nehls de- Study settings scribes this in the context of narratives; lived experiences Mannequin based simulation (high fidelity 5 527 shared for the purpose of learning [27]. The addition of simulation - HFS) “active watching” to Nehls’ definition fits well in the Simulated patient (SP) 2 324 simulation context. In a review of vicarious learning, Actor (improvisation rather than scripted SP) 1 192 Roberts concludes that vicarious learning occurs during Role play by participant group 1 160 story telling and discourse, and may require a teacher to Study design help find meaning [28]. In the context of scenario-based simulation the story is the scenario or case; active listen- Post test only (Knowledge) 1 92 ing and watching is engaged with the use of tools or Pre-test/post-test 1 group 1 157 tasks and the reflective facilitated discussion is the Pre-test/post-test 2 groups 2 344 debriefing. It seems important that for optimal learning Self-assessment pre-test and post-test 3 476 to occur, observers be engaged in all aspects including Self-assessment post-test only 1 84 the debrief. Observer role allocation Experiential learning is viewed as fundamental to simulation and clinical practice [29, 30] and the theoret- Randomised 5 643 ical foundations of simulation are commonly described Self allocation 1 84 in terms of Kolb’s experiential learning cycle [29]. Kolb Unclear 2 284 proposes a cycle of concrete experiences which on re- Outcome flection are distilled into abstract concepts that can then Knowledge 6 869 provide the basis for future actions and further testing Skills - technical 3 441 [31]. Kolb stresses that this is an unending cycle and ed- ucators need to be aware that learners have a preference Skills - non technical 8 1059 for, and may enter at different stages of the experiential Attitudes 2 134 learning cycle, but need to be moved through the entire Behaviours 1 84 process. A dangerous presumption for educators and Learning outcomes by role learners alike is that concrete experience requires hands- Participatory role better than observer 2 208 on participation. Vicarious learning theory and Kolb’s Observer role better than participatory 1 200 experiential learning cycle form the theoretical basis for directed observation. No difference 4 588 It seems that observers with the appropriate tools Satisfaction by role can benefit vicariously from the experience of the Participatory role more valued than observer 2 208 hands-on learners. Simulation is a facsimile of the Observer role more valued than participatory 1 144 clinical environment so the findings here may also No difference in value 3 334 translate to observation in similar clinical practice sit- Observational tool used 6 803 uations. This directed observer role is different to indirect workplace learning described by Le Clus, Debriefing/feedback where the emphasis is on observers seeking learning Observer led pairs 1 200 to meet their personal needs [32]. However, the con- Faculty led group debrief 7 811 cept of observer learning as a social practice aligns Feedback guide 1 200 with both [24, 32]. O’Regan et al. Advances in Simulation (2016) 1:4 Page 8 of 10 Stegmann reports better outcomes from observers pre- incongruent hand-on roles in these studies prevents paring to provide feedback than those completing a drawing any real conclusions from the data. In a re- checklist or in a hands-on role [15]. The impending ‘de- port of alarge studyfor theNationalLeague of brief ’ where observers have an expectation that they will Nurses Jefferies and Rizzola concluded that whilst be asked to contribute their opinions about the encoun- knowledge and self-confidence were unrelated to role ter may sharpen the focus of their observations. Bandura allocation, there was a perceived lack of collaboration describes this as an external motivator [25]. This ‘height- in theobserverrole and therewas aresponsibilityfor ened state’ may mean observers are more likely to en- educators to provide structure for this to occur [9]. gage in standards of practice required for the simulation While learners have assessed the value of observer (for example, measures of good communication) and roles, there has not been a published assessment of consider how the simulation participant’s performance the value placed upon observer roles in simulation by measures up to this standard. Thidemann used reporting educators or facilitators. Use of observer tools or on standards of practice in her directed observer role activities and the active involvement of observers in guidelines [16]. the post-scenario debrief could be considered an in- The learners who did not value observer roles as direct indication of the value educators place on highly as a hands-on role described observer roles as learning in observer roles. passive, or boring [20]. They were not fully engaged in It is also unclear as to whether there is a group of the learning process. Emotional engagement in simula- learners better suited to learning through observation tion is connected to the feeling of relevance of the sce- than learning through hands-on participation in the nario to the goals of the session [24]. Lack of goal simulation. Whilst most of the studies used role alloca- direction may have prevented observer engagement. It is tion, one study [20] had a portion of study participants not clear whether there is an optimal level of activation who either self allocated or worked through the case as for learning in observer roles or whether it differs be- a group without assigned roles. There was confusion tween learners. Learners that valued observer roles de- amongst the students in this study as to which roles scribed it as being less stressful and providing them the were considered to be observers; for example some stu- opportunity to see the big picture, examine details from dents viewed the documentation nurse as an observer a distance, and provide meaningful feedback to the team role while others viewed it as a hands-on role. No stud- [11]. Stress decompression, a feature of debriefing ies examined whether self-allocation to roles would re- frameworks, is necessary for reflection [30, 33]. sult in better learning outcomes. The reasons behind The ability to reflect is important in the provision of self-allocation were also not examined and may be feedback. An understanding of performance require- worthy of further study. ments and a judgement regarding the observed perform- An important area for further study includes establish- ance and its relationship to the standard is required ing educator perceived value of observational roles, and before bridging strategies can be formulated [34]. In di- the potential impact of these perceptions on simulation rected observer roles, information was provided in the education design and orientation of learners to roles form of the observer tool (e.g. checklist) defining the within the scenarios. Activation and emotional engage- standards and/or objectives for the learners. The di- ment in the observer role has also not been explored, rected observers were able to use these tools to observe, and provides future research potential. reflect upon and formulate their peer feedback for the debrief. Limitations In-scenario observers, that is non-clinical or other This review examines one small area of observational professional roles within the scenario, reported that learning within scenario-based simulation. Skills train- lack of scripts or clear direction detracted from the ing, which is often taught in groups was not included. act of observation because of anxiety regarding role Also excluded were non peer-reviewed reports, including performance requirements [20]. These aspects of role a major study of more than 400 nurses [9]. This report fidelity have been identified as a barrier to student did however inform the discussion. We also narrowly satisfaction with role play [35]. The other studies that defined simulation modalities excluding virtual reality used non-clinical or other non-congruent professional simulations where there is even more blurring of bound- roles viewed these learners as hands-on participants aries between hands-on participants and observer roles. and did not include specific findings for these in- In some studies it was unclear how the authors defined scenario observer roles [17, 20, 21]. Thidemann com- the in-scenario roles. Reporting of observer roles was in mented that the nursing roles in their scenarios were some cases a secondary finding. Lack of clarity may have the most preferred roles [16]. The lack of clarity in biased findings. The small number of included papers the separation between professionally congruent and also limits the conclusions. O’Regan et al. Advances in Simulation (2016) 1:4 Page 9 of 10 Conclusion 5. LeFlore JL, Anderson M. 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A critical review of simulation-based medical education research: 2003-2009. Med Educ. 2010; (see study limitations). 44(1):50–63. 13. Moher D, Liberati A, Tetzlaff J, Altman D. Preferred reporting Items for Competing interests systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. Stephanie O’Regan declares she has no competing financial or other 2009;6(6):e1000097. interests. 14. Buckley S, Coleman J, Davison I, Khan KS, Zamora J, Malick S, et al. The Elizabeth Molloy declares she has no competing financial or other interests educational effects of portfolios on undergraduate student learning: A Best Leonie Watterson declares she has no competing financial or other interests Evidence Medical Education (BEME) systematic review. BEME Guide No. 11. Debra Nestel is the Editor in Chief of Advances in Simulation. She has no Med Teach. 2009;31(4):302. other competing interests. 15. Stegmann K, Pilz F, Siebeck M, Fischer F. Vicarious learning during simulations: is it more effective than hands-on training? Med Educ. 2012; 46(10):1001–8. Authors’ contributions 16. Thidemann IJ, Soderhamn O. High-fidelity simulation among bachelor SO conceived the study, drafted the study design, search protocol, students in simulation groups and use of different roles. Nurs Educ Today. conducted the search, selected the included studies, participated in the 2013;33(12):1599–604. study ratings and drafted the manuscript. EM refined the study design and 17. Lau KC, Stewart SM, Fielding R. Preliminary evaluation of "interpreter" role search protocol, participated in the study rating, helped draft the manuscript plays in teaching communication skills to medical undergraduates. Med and contributed to the background literature. LW helped draft the manuscript Educ. 2001;35(3):217–21. and contributed to the background literature. DN refined the study design and 18. Stiefel F, Bourquin C, Layat C, Vadot S, Bonvin R, Berney A. Medical students' search protocol, helped draft the manuscript and contributed to the skills and needs for training in breaking bad news. J Cancer Educ. 2013; background literature. All authors read an approved the final manuscript. 28(1):187–91. 19. Bell SK, Pascucci R, Fancy K, Coleman K, Zurakowski D, Meyer EC. The Acknowledgements educational value of improvisational actors to teach communication and There are no other acknowledgments to be made for this manuscript. The relational skills: perspectives of interprofessional learners, faculty, and actors. authors received no external funding for the data collection or preparation Patient Educ Counsel. 2014;96(3):381–8. of this manuscript. 20. Harder N, Ross CJM, Paul P. Student perspective of role assignment in high- fidelity simulation: an ethnographic study. Clin Sim Nurs. 2013;9(9):e329–e34. Author details 21. Smith KV, Klaassen J, Zimmerman C, Cheng AL. The evolution of a high- Sydney Clinical Skills and Simulation Centre, Royal North Shore Hospital, fidelity patient simulation learning experience to teach legal and ethical Level 6 Kolling Building, Reserve Rd, St Leonards, NSW 2065, Australia. issues. J Prof Nurs. 2013;29(3):168–73. Health Professions Education and Educational Research (HealthPEER), 22. Kaplan BG, Abraham C, Gary R. Effects of participation vs. observation of a Faculty of Medicine, Nursing and Health Sciences, Monash University, simulation experience on testing outcomes: implications for logistical Building 13C, Office G09, Clayton Campus, Victoria 3800, Australia. planning for a school of nursing. Int J Nurs Educ Scholarship. 2012;9(1) doi:10.1515/1548-923X.2398. Received: 30 July 2015 Accepted: 18 December 2015 23. Sanders A, Bellefeuille P, van Schaik S. Emotional impact of active versus observational roles during simulation learning. Sim Healthcare; 2013;8(6) p. 589. 24. Dieckmann P, Gaba D, Rall M. 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Observer roles that optimise learning in healthcare simulation education: a systematic review

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Springer Journals
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Copyright © 2016 by O'Regan et al
Subject
Medicine & Public Health; Medicine/Public Health, general
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2059-0628
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10.1186/s41077-015-0004-8
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Abstract

Background: Simulation is widely used in health professional education. The convention that learners are actively involved may limit access to this educational method. The aim of this paper is to review the evidence for learning methods that employ directed observation as an alternative to hands-on participation in scenario-based simulation training. We sought studies that included either direct comparison of the learning outcomes of observers with those of active participants or identified factors important for the engagement of observers in simulation. We systematically searched health and education databases and reviewed journals and bibliographies for studies investigating or referring to observer roles in simulation using mannequins, simulated patients or role play simulations. A quality framework was used to rate the studies. Methods: We sought studies that included either direct comparison of the learning outcomes of observers with those of active participants or identified factors important for the engagement of observers in simulation. We systematically searched health and education databases and reviewed journals and bibliographies for studies investigating or referring to observer roles in simulation using mannequins, simulated patients or role play simulations. A quality framework was used to rate the studies. Results: Nine studies met the inclusion criteria. Five studies suggest learning outcomes in observer roles are as good or better than hands-on roles in simulation. Four studies document learner satisfaction in observer roles. Five studies used a tool to guide observers. Eight studies involved observers in the debrief. Learning and satisfaction in observer roles is closely associated with observer tools, learner engagement, role clarity and contribution to the debrief. Learners that valued observer roles described them as affording an overarching view, examination of details from a distance, and meaningful feedback during the debrief. Learners who did not value observer roles described them as passive, or boring when compared to hands-on engagement in the simulation encounter. Conclusions: Learning outcomes and role satisfaction for observers is improved through learner engagement and the use of observer tools. The value that students attach to observer roles appear contingent on role clarity, use of observer tools, and inclusion of observers’ perspectives in the debrief. Keywords: Simulation, Observer, Observer role, Directed observer, Vicarious learning * Correspondence: saoregan@msn.com Sydney Clinical Skills and Simulation Centre, Royal North Shore Hospital, Level 6 Kolling Building, Reserve Rd, St Leonards, NSW 2065, Australia Full list of author information is available at the end of the article © 2016 O’Regan et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. O’Regan et al. Advances in Simulation (2016) 1:4 Page 2 of 10 Background Methods There has not been a systematic review of the factors The search was conducted over five databases (Medline, that promote learning in the observer roles in simula- Cinahl, PsycINFO, EmBase and ERIC) within a publica- tion. As more learners are allocated to observer roles tion period of 1980 – July 2015 using 45 search terms there is an imperative to ensure that learning in this role and restricted to the English language. Hand searching is optimised. This review seeks to synthesise the factors of grey literature, journal contents and reference lists that focus the observers’ learning and satisfaction in the was also undertaken. The study population included any role and provide educators with guidance to employing healthcare professional or student who participated in observer roles within their simulations. mannequin, simulated patient (actor) or role-play based Simulation is an effective healthcare teaching strategy simulations that included a specific observer role (Table 1). [1] and can improve knowledge, skills and behaviours Studies selected included either direct comparison of the when compared to traditional or no teaching [2]. Simu- learning outcomes of observers with those of active partic- lation conventionally enables learners to physically par- ipants following the simulation or identified the factors ticipate in realistic scenarios replicating real world important for the engagement of observers in simulations practice and has been reported as an effective replace- and needed to identify their outcome measures and in- ment for clinical hours for nursing students [3]. Increas- clude changes in knowledge, skills, attitudes or behaviours ing demand, cohort numbers and access limitations, of participants (Table 2) Specific exclusions included com- particularly in professional entry programs has resulted puter or virtual reality based simulations as the observer in innovative approaches for learners using simulation. role was difficult to define, and specific task or skill train- These approaches include role modelling [4, 5], peer and ing as the teaching methodology is different than case near-peer assisted learning [6–8], and alternative based scenarios. Video based learning and expert role instructional design methods whereby learners are actively directed to observe without hands-on participa- Table 1 Search terms tion [9–11]. We refer to this as the directed observer. Population Intervention Outcome When simulation is used appropriately, it improves Nurs* or Simulation or Learn* or learning outcomes [2, 12]. However, the evidence midwif* or Patient simulation or Knowledge or supporting learning by observation is less clear. Medic* or Manikin* or Skill* or This review presents evidence supporting directed ob- servation as an educational method and features of this doctor or Mannequin* or Attitude* or method that lead to positive educational outcomes. surgery or Simulated patient* or Behav* The literature is not always clear on what constitutes Allied health or Standardised patient* or observer roles. Here, observer roles are defined as two Physiotherap* or Standardized patient* or broad types. First, roles where the learner is external to Occupational therap* or Role play or the simulation. For example, the learner will be watching Dental or Actor or but not participating in the simulation, either within the simulation area or from an area removed from the simu- Dentist* or Acting or lation. Second, roles where the learner is given a role in Social work* or theatre the simulation that is not congruent with their profes- Respiratory therap* or sional one. For example, a nursing student could realis- Dietet* or AND tically be expected to perform the roles of medication Paramedic* or Observ* or nurse, bedside nurse or documentation nurse in their Aboriginal torres strait Observ* role or professional activities. However, they would not be a doctor, social worker or patient relative. In this paper, islander health or Observational learn* or we describe these roles as ‘in-scenario’ observer roles. Fur- Indigen* or Vicarious learn* or ther, observers are described as having a ‘directed obser- Inter professional or Watching ver’ role or a ‘non-directed’ role. A directed observer role Interprofessional or would include a specific instructional briefing or use of an Intra professional or observer tool. A non-directed observer watches without Intraprofessional or specific guidance or objectives. The instructional briefing or observer tool contains information for the directed Multi disciplin* or observer on specific learning objectives, behaviours or Multidisciplin* or activities to consider, points for peer feedback or a check- Multi profession* or list to measure against. These specifics would then form Multiprofession* part of the debrief. O’Regan et al. Advances in Simulation (2016) 1:4 Page 3 of 10 Table 2 Inclusion and exclusion criteria Inclusion/Exclusion Criteria Criterion Inclusion Exclusion Population Clinicians and students of any health profession Non health professionals Intervention Undergoing a mannequin or simulated patient based Computer based, skill or part-task trainers, virtual reality, or cadaveric learning experience and simulation/simulators. � Examines the role of the observer � Studies which do not explicitly examine the observer role. � Has an observer role defined as a learner within a scenario � Observers who are not participating in the learning, for example not in a clinically congruent role or observers for the purpose of research study. � Has an observer role external to scenario participant roles � Expert modelling for learning Outcome measures � A direct or indirect change in knowledge, skills, attitudes � Description of behaviours without consideration of any changes or behaviours in learner behaviour Citations Peer reviewed papers in the english language from 1980 to � Non peer reviewed publications e.g thesis or reports th October 4 2014. � Descriptive papers � Published texts or books modelling were also excluded, as there is no comparison of hands-on and observer roles (Table 2). Results Nine studies were selected from the 5469 potential papers identified using the PRISMA process [13] (Fig. 1). The studies are summarised in Table 3. The included studies used quantitative, qualitative and mixed methods. A modi- fied version of Buckley’s quality indicators, devised for assessment of quantitative, qualitative and mixed methods studies was selected as the quality assessment tool [14]. These 11 quality indicators relate to the appropriateness of study design, conduct, results analysis and conclusions and are not biased towards any particular research meth- odology (Table 4). Two reviewers (SO, EM) rated the quality of the stud- ies with an inter-rater agreement of 0.94 across 99 data points. Seven studies meeting seven or more criteria as specified by Buckley, were considered high quality stud- ies [14]. There was a wide range of quality with scores from 3 to 11 out of a possible 11. Most common prob- lems encountered were with data completeness, control for confounders, study replicability and addressing ethical issues. Two studies, Stegmann [15] and Thidemann, [16] met all 11 criteria. Two studies, Lau [17] and Stiefel, [18] met six or less criteria. Rater differences are shown in the table as two scores, with the lowest total score reported where there was a discrepancy (Table 4). To provide composite data the nine included studies were examined using categories adapted from Cook et al [2]. There were a total of 1203 participants across the nine studies with the majority of studies focusing on undergraduate students in nursing (n = 527) and medi- cine (n = 484). There was one interprofessional study in- volving practising clinicians across four disciplines [19]. Five studies used mannequin-based simulations [11, 16, Fig. 1 Search flow diagram using the PRISMA process 20–22], two employed simulated patients [15, 18], one O’Regan et al. Advances in Simulation (2016) 1:4 Page 4 of 10 Table 3 Summary of selected studies Reference Research paradigm, design & Participants Intervention Learner Observation Style Results sampling Bell, Pascucci, Fancy, Mixed methods Health professionals from Use of improvisational actors in Non-directed role: no use of No difference between observers Coleman, Zurakowski and four disciplines (n =192) difficult conversations to teach observational tool or verbal and hands on learners in: Meyer [24] communication and relational guidance reported perceived realism; usefulness of Post-simulation survey design Teaching faculty (n = 33) skills to practicing health actors; usefulness of scenarios; with qualitative and quantitative professional and, opinions on non-actor role analysis play Convenience sample Actors (SP) (n = 10) Hands on participants (47 %) Observers (53 %) Harder, Ross and Paul [25] Ethnographic stud Bachelor of Nursing Role assignment within regular Non-directed role: no use of Students preferred assignment to students year 3 (n = 84) simulation session with analysis of observer tool or verbal nursing roles rather than observer experience and perceptions of guidance reported or non nursing role learning within different role Observational design with Participant/observation All participants experienced both Structured role descriptions focused interview and journal (n = 84) interview (n = 12) roles positively affected learning review of selected participants outcomes Volunteer sample journal review (n =4) Hober and Bonnel [11] Qualitative Bachelor of Nursing “senior” Immersive simulation scenarios Directed observer role: Observer role beneficial, less students (n = 50) with students randomly assigned observer tool – educator stressful to active or observer roles provided activity guidelines Survey and interview design Observers (n = 23) All completed survey Use of a guided observer tool useful Convenience sample hands on learners (n = 27) Observers interviewed Able to reflect in action and on action Kaplan, Abraham and Gary [27] Quantitative Bachelor of Nursing “junior” Immersive simulation scenarios - Directed observer role: No difference in knowledge students (n = 92) observer tool -checklist Randomised groups Observers (n = 46) participants self selected roles Convenience sample Scenario participants Unclear whether observers self Limited as aggregated post (n = 46) selected or were assigned satisfaction survey data Post scenario knowledge test and satisfaction survey Lau, Stewart and Fielding [22] Quasi experimental Medical students (bilingual) Student role plays with Directed observer role: Observers rated post knowledge randomised to roles year 1 (n = 160) comparison of learning between observer tool -checklist higher than learners in interpreter interpreter role play and observer role-play role Convenience sample Self rated pre & post knowledge O’Regan et al. Advances in Simulation (2016) 1:4 Page 5 of 10 Table 3 Summary of selected studies (Continued) Smith, Klaassen, Zimmerman Mixed methods with Bachelor of Nursing “junior” Introduction of simulation year 1 Non-directed role: no use of No significant difference in and Cheng [26] increasing variables over three students observational tool or verbal learning outcomes, student Introduction non nursing years guidance reported perceptions or peer evaluations participatory roles year Convenience sample year 1 (n = 67) Introduction non participatory observer roles year 3 year 2 (n =72) year 3 (n =85) Note only the year 2 and 3 data were included in review Stegmann, Pilz, Siebeck and Quantitative Medical students (n = 200) Comparison of participatory role Non-directed and directed Observational learning (especially Fischer [20] and observer role in simulated observer roles compared: if supported by observer script) Crossover design 2x2x2 patient scenario with and without checklists and feedback scripts more effective than learning by pre-test post-test observation tool used doing Stiefel, Bourquin, Layat, Quantitative Medical students (masters Individual training with simulated Non-directed role: no use of Measured outcomes no difference Vadot, Bonvin and Berney level) (n = 124) patient encounter observer tool or verbal [23] guidance reported Randomised into 2 group Individual training (n = 49) Group training with simulated Those who observed but did not Group training (n = 75) patient encounter participate felt they did not meet -participated in simulation their learning objectives as well Evaluation using instructor Group training with observation (n = 14) observed (n =61) compared to the other 2 groups rating scale and student of simulated encounter questionnaire Convenience sample Thidemann and Soderhamn Quasi experimental Bachelor of Nursing student Immersive mannequin simulation Directed observer role: Post-test scores higher in all [21] year 2 (n =144) with random allocation to groups observer tool with specific task groups independent of rol focus Pre - and post-simulation Four volunteers within each More satisfaction with nurse role knowledge test and student group allocated to participatory questionnaire and in scenario observer roles – remainder observers (n = 72) Convenience sample over two consecutive years as attributed by author where available O’Regan et al. Advances in Simulation (2016) 1:4 Page 6 of 10 Table 4 Study ratings using Buckley's (modified) criteria Criteria (Yes, No, Unclear) Bell Harder Hober Kaplan Lau Smith Stegmann Stiefel Thidemann Note: rater disagreement shown as two scores Clear research question U Y Y Y U Y Y U Y Subject group appropriate for study Y Y Y Y Y Y Y Y Y Reliable and valid methods (qualitative or quantitative) used Y Y Y Y Y/U Y Y Y Y Completeness of data (drop out, questionnaire response rate >60 %, YY Y Y N N Y N Y attrition rate <50 %) Controlled for confounders or acknowledged if non RCT design N U/N N U/N U N Y U Y Statistical and other analysis methods appropriate Y Y Y Y Y Y Y Y Y Data justifies the conclusions drawn Y Y Y Y N Y Y U/N Y Study could be replicated Y/U Y Y Y U N/U Y Y Y Prospective study Y Y Y Y Y Y Y Y Y Relevant ethical issues addressed U Y Y N U Y Y U Y Triangulation of data Y Y Y Y N Y Y N Y Total Score/11 (lowest score reported) 7 10 10 9 3 8 11 5 11 an actor [19], and one study involved role-play by the valued the hands-on roles higher did not employ an ob- participant group [17] (Table 5). server tool for the observer group [18]. The observer Eight of the nine studies compared knowledge, skills, tools included performance checklists [15, 17, 22], feed- attitudes or behaviours between the hands-on role and back or observation guides [11, 15], or observer role in- the observer role [11, 15, 17, 18, 20–22]. Six studies used structional briefing [16]. All studies except Bell [23] a pre and post-test design, three of which were self- documented including observers in the post simulation assessment of improvement in knowledge and/or skills debrief or feedback. [17–19] and three studies tested knowledge [15, 16, 21]. Two studies examined knowledge in a post-test only Discussion design [22] one of which was a self-assessment [20]. We sought reported factors that contribute to the opti- Outcomes included knowledge (six), ‘non-technical skills’ misation of learning in the observer role. It is clear from (eight), technical skills (three), attitudes (two) and behav- this review that the use of observer tools to focus the iours (one). observer and role clarity are strongly associated with Four studies found no difference in outcomes between role satisfaction and learning outcomes in observer roles. the hands-on learners and the observers [11, 16, 19, 22]. This finding is supported by Bandura’s social learning Two studies reported superior outcomes in the hands- theory and Kolb’s experiential learning cycle and we on group [18, 20] and one study reported better out- propose that these form the basis of the directed obser- comes in the observer group [15]. The study that found ver role. superior outcomes for the observer group and three of One of the outstanding findings from this review is the four studies that found no difference in outcomes the association of observer tools with both satisfaction between the hands-on and observer groups [15–17, 22] and equal if not better, learning outcomes in observer incorporated an observer tool to guide the observer roles. The use of these tools may move observers from group. Neither study that demonstrated superior out- simply watching to actively observing. The activation of comes by the hands-on learners employed an observer observers allows those in that role to experience the sat- tool [18, 20]. isfaction and learning normally associated with hands- Six studies considered the perceived value of the on experience. Simulation is described by Dieckmann et hands-on learner and observer roles to the participants. al as a social practice where people interact with each Two studies reported that participants valued the hands- other in a goal orientated fashion [24]. The observer tool on roles more than the observer role [18, 20], one study provides this necessary goal orientation for observer highly valued the observer role [16] and three studies re- roles. Directed observers are focused on the learning ob- ported no difference in the value of the roles [11, 19, jectives of the simulation. 22]. Two of the three studies with no value difference in This is explained by Bandura’s social learning theory, roles [11, 22], and the study that valued the observer which proposes that virtually all learning acquired ex- role highly [16] used an observer tool. The study that perientially could also be acquired on “a vicarious basis O’Regan et al. Advances in Simulation (2016) 1:4 Page 7 of 10 Table 5 Characteristics of included studies through observation of other people’s behaviour and its consequences for them” [25]. Through observation Study Characteristics Number of Number of Studies Participants learners can build behaviours without trial and error, ex- All studies 9 1203 perience emotions by watching others and resolve fears through other’s experience. Bandura describes this as a Study participants process of attention, retention, reproduction and motiv- Medical students 3 484 ation [25]. Bethards reports on a program where “simu- Nursing students 5 527 lation experiences are designed around the observer role Practicing clinicians 1 using the four component processes of Bandura’s observa- Physician 43 tional learning construct” [26]. They postulate that this Nurse 114 provides all their learners, regardless of role, the same opportunities to achieve the learning objectives [26]. “Psychosocial clinicians” 20 Vicarious learning requires active listening, reflective Medical interpreter 14 thinking and situational engagement [27]. Nehls de- Study settings scribes this in the context of narratives; lived experiences Mannequin based simulation (high fidelity 5 527 shared for the purpose of learning [27]. The addition of simulation - HFS) “active watching” to Nehls’ definition fits well in the Simulated patient (SP) 2 324 simulation context. In a review of vicarious learning, Actor (improvisation rather than scripted SP) 1 192 Roberts concludes that vicarious learning occurs during Role play by participant group 1 160 story telling and discourse, and may require a teacher to Study design help find meaning [28]. In the context of scenario-based simulation the story is the scenario or case; active listen- Post test only (Knowledge) 1 92 ing and watching is engaged with the use of tools or Pre-test/post-test 1 group 1 157 tasks and the reflective facilitated discussion is the Pre-test/post-test 2 groups 2 344 debriefing. It seems important that for optimal learning Self-assessment pre-test and post-test 3 476 to occur, observers be engaged in all aspects including Self-assessment post-test only 1 84 the debrief. Observer role allocation Experiential learning is viewed as fundamental to simulation and clinical practice [29, 30] and the theoret- Randomised 5 643 ical foundations of simulation are commonly described Self allocation 1 84 in terms of Kolb’s experiential learning cycle [29]. Kolb Unclear 2 284 proposes a cycle of concrete experiences which on re- Outcome flection are distilled into abstract concepts that can then Knowledge 6 869 provide the basis for future actions and further testing Skills - technical 3 441 [31]. Kolb stresses that this is an unending cycle and ed- ucators need to be aware that learners have a preference Skills - non technical 8 1059 for, and may enter at different stages of the experiential Attitudes 2 134 learning cycle, but need to be moved through the entire Behaviours 1 84 process. A dangerous presumption for educators and Learning outcomes by role learners alike is that concrete experience requires hands- Participatory role better than observer 2 208 on participation. Vicarious learning theory and Kolb’s Observer role better than participatory 1 200 experiential learning cycle form the theoretical basis for directed observation. No difference 4 588 It seems that observers with the appropriate tools Satisfaction by role can benefit vicariously from the experience of the Participatory role more valued than observer 2 208 hands-on learners. Simulation is a facsimile of the Observer role more valued than participatory 1 144 clinical environment so the findings here may also No difference in value 3 334 translate to observation in similar clinical practice sit- Observational tool used 6 803 uations. This directed observer role is different to indirect workplace learning described by Le Clus, Debriefing/feedback where the emphasis is on observers seeking learning Observer led pairs 1 200 to meet their personal needs [32]. However, the con- Faculty led group debrief 7 811 cept of observer learning as a social practice aligns Feedback guide 1 200 with both [24, 32]. O’Regan et al. Advances in Simulation (2016) 1:4 Page 8 of 10 Stegmann reports better outcomes from observers pre- incongruent hand-on roles in these studies prevents paring to provide feedback than those completing a drawing any real conclusions from the data. In a re- checklist or in a hands-on role [15]. The impending ‘de- port of alarge studyfor theNationalLeague of brief ’ where observers have an expectation that they will Nurses Jefferies and Rizzola concluded that whilst be asked to contribute their opinions about the encoun- knowledge and self-confidence were unrelated to role ter may sharpen the focus of their observations. Bandura allocation, there was a perceived lack of collaboration describes this as an external motivator [25]. This ‘height- in theobserverrole and therewas aresponsibilityfor ened state’ may mean observers are more likely to en- educators to provide structure for this to occur [9]. gage in standards of practice required for the simulation While learners have assessed the value of observer (for example, measures of good communication) and roles, there has not been a published assessment of consider how the simulation participant’s performance the value placed upon observer roles in simulation by measures up to this standard. Thidemann used reporting educators or facilitators. Use of observer tools or on standards of practice in her directed observer role activities and the active involvement of observers in guidelines [16]. the post-scenario debrief could be considered an in- The learners who did not value observer roles as direct indication of the value educators place on highly as a hands-on role described observer roles as learning in observer roles. passive, or boring [20]. They were not fully engaged in It is also unclear as to whether there is a group of the learning process. Emotional engagement in simula- learners better suited to learning through observation tion is connected to the feeling of relevance of the sce- than learning through hands-on participation in the nario to the goals of the session [24]. Lack of goal simulation. Whilst most of the studies used role alloca- direction may have prevented observer engagement. It is tion, one study [20] had a portion of study participants not clear whether there is an optimal level of activation who either self allocated or worked through the case as for learning in observer roles or whether it differs be- a group without assigned roles. There was confusion tween learners. Learners that valued observer roles de- amongst the students in this study as to which roles scribed it as being less stressful and providing them the were considered to be observers; for example some stu- opportunity to see the big picture, examine details from dents viewed the documentation nurse as an observer a distance, and provide meaningful feedback to the team role while others viewed it as a hands-on role. No stud- [11]. Stress decompression, a feature of debriefing ies examined whether self-allocation to roles would re- frameworks, is necessary for reflection [30, 33]. sult in better learning outcomes. The reasons behind The ability to reflect is important in the provision of self-allocation were also not examined and may be feedback. An understanding of performance require- worthy of further study. ments and a judgement regarding the observed perform- An important area for further study includes establish- ance and its relationship to the standard is required ing educator perceived value of observational roles, and before bridging strategies can be formulated [34]. In di- the potential impact of these perceptions on simulation rected observer roles, information was provided in the education design and orientation of learners to roles form of the observer tool (e.g. checklist) defining the within the scenarios. Activation and emotional engage- standards and/or objectives for the learners. The di- ment in the observer role has also not been explored, rected observers were able to use these tools to observe, and provides future research potential. reflect upon and formulate their peer feedback for the debrief. Limitations In-scenario observers, that is non-clinical or other This review examines one small area of observational professional roles within the scenario, reported that learning within scenario-based simulation. Skills train- lack of scripts or clear direction detracted from the ing, which is often taught in groups was not included. act of observation because of anxiety regarding role Also excluded were non peer-reviewed reports, including performance requirements [20]. These aspects of role a major study of more than 400 nurses [9]. This report fidelity have been identified as a barrier to student did however inform the discussion. We also narrowly satisfaction with role play [35]. The other studies that defined simulation modalities excluding virtual reality used non-clinical or other non-congruent professional simulations where there is even more blurring of bound- roles viewed these learners as hands-on participants aries between hands-on participants and observer roles. and did not include specific findings for these in- In some studies it was unclear how the authors defined scenario observer roles [17, 20, 21]. Thidemann com- the in-scenario roles. Reporting of observer roles was in mented that the nursing roles in their scenarios were some cases a secondary finding. Lack of clarity may have the most preferred roles [16]. The lack of clarity in biased findings. The small number of included papers the separation between professionally congruent and also limits the conclusions. O’Regan et al. Advances in Simulation (2016) 1:4 Page 9 of 10 Conclusion 5. LeFlore JL, Anderson M. 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A critical review of simulation-based medical education research: 2003-2009. Med Educ. 2010; (see study limitations). 44(1):50–63. 13. Moher D, Liberati A, Tetzlaff J, Altman D. Preferred reporting Items for Competing interests systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. Stephanie O’Regan declares she has no competing financial or other 2009;6(6):e1000097. interests. 14. Buckley S, Coleman J, Davison I, Khan KS, Zamora J, Malick S, et al. The Elizabeth Molloy declares she has no competing financial or other interests educational effects of portfolios on undergraduate student learning: A Best Leonie Watterson declares she has no competing financial or other interests Evidence Medical Education (BEME) systematic review. BEME Guide No. 11. Debra Nestel is the Editor in Chief of Advances in Simulation. She has no Med Teach. 2009;31(4):302. other competing interests. 15. Stegmann K, Pilz F, Siebeck M, Fischer F. 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Published: Jan 11, 2016

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