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Optimisation of simulated team training through the application of learning theories: a debate for a conceptual framework

Optimisation of simulated team training through the application of learning theories: a debate... Background: As a conceptual review, this paper will debate relevant learning theories to inform the development, design and delivery of an effective educational programme for simulated team training relevant to health professionals. Discussion: Kolb’s experiential learning theory is used as the main conceptual framework to define the sequence of activities. Dewey’s theory of reflective thought and action, Jarvis modification of Kolb’s learning cycle and Schön’s reflection-on-action serve as a model to design scenarios for optimal concrete experience and debriefing for challenging participants’ beliefs and habits. Bandura’s theory of self-efficacy and newer socio-cultural learning models outline that for efficient team training, it is mandatory to introduce the social-cultural context of a team. Summary: The ideal simulated team training programme needs a scenario for concrete experience, followed by a debriefing with a critical reflexive observation andabstractconceptualisation phase, andendingwitha second scenario for active experimentation. Let them re-experiment to optimise the effect of a simulated training session. Challenge them to the edge: The scenario needs to challenge participants to generate failures and feelings of inadequacy to drive and motivate team members to critical reflect and learn. Not experience itself but the inadequacy and contradictions of habitual experience serve as basis for reflection. Facilitate critical reflection: Facilitators and group members must guide and motivate individual participants through the debriefing session, inciting and empowering learners to challenge their own beliefs and habits. To do this, learners need to feel psychological safe. Let the group talk and critical explore. Motivate with reality and context: Training with multidisciplinary team members, with different levels of expertise, acting in their usual environment (in-situ simulation) on physiological variables is mandatory to introduce cultural context and social conditions to the learning experience. Embedding in situ team training sessions into a teaching programme to enable repeated training and to assess regularly team performance is mandatory for a cultural change of sustained improvement of team performance and patient safety. Keywords: Teamwork, Team training, In-situ simulation, Experiential learning theory, Socio-cultural learning theories, Conceptual framework Background and teamwork) during critical events has repeatedly During the last decade medical and nursing authorities been shown to contribute to adverse events and poor and societies have increasingly recognised the critical patient outcomes [5-9]. The benefit of simulation train- importance of team training as a mandatory domain for ing for non-technical skills for critical events has been health professional education [1-4]. Suboptimal perform- shown in several studies to improve patient safety ance in non-technical skills (communication, leadership [10-16]. However, there is on-going debate as to which is the most effective way to provide simulation team training to health professionals [11-13,17-21]. * Correspondence: martin.stocker@luks.ch Individuals bring assumptions about themselves, others Neonatal and Paediatric Intensive Care Unit, Children’s Hospital Lucerne, and events to learning opportunities. These different views Spitalstrasse, Lucerne 16 CH-6000, Switzerland of reality are our personal “conceptual frameworks” [22]. Full list of author information is available at the end of the article © 2014 Stocker et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. 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. Stocker et al. BMC Medical Education 2014, 14:69 Page 2 of 9 http://www.biomedcentral.com/1472-6920/14/69 A debate with critical appraisal of conceptual frameworks involvement in a specific experience (such as doing or can lead educator and researcher to alternate views, with feeling); then they reflect on the experience from a variety potential impact on design or assessment of educational of perspectives (reflective observation such as examining programmes [22]. In a recent review of the literature or watching). Through reflection learners integrate their regarding experimental studies in medical education, only observations into more abstract models, create gener- half of the authors declared their conceptual frameworks alisations and principles and draw conclusions (abstract [23]. We have recently published our simulated team conceptualization such as explaining or thinking). The training programme, with no reference to the underlying individual then uses these principles and conclusions to conceptual framework [24]. Debating the educational guide subsequent decisions and actions (active experimen- framework underlying a simulation programme may tation such as applying or doing) that lead to new con- improve effectiveness, impact on team performance crete experiences [31]. and hence patient safety. Hodges has recently advo- According to Kolb’s four-stage experiential learning cated the use of bioscience, learning and sociocultural cycle, immediate and concrete experiences are the basis theories to design and conduct medical education pro- for observations and reflections [31]. Consequently all grammes [25]. The following discussion will explore participants in a simulated team training programme key educational frameworks and highlight aspects and need to begin by completing a simulated critical event debates that inform the development, design and deliv- (Figure 2). They then come together for structured ery of an effective educational programme for simu- debriefing [26,29,32]. Debriefing addresses the second and lated team training relevant to health professionals. third phases of Kolb’s cycle: reflective observation, then abstract conceptualization. Reflective observation de- Discussion scribes observation and analysis of a concrete experience. Debate 1: Single versus repeated exposure in one This is mainly characterized through participants’ narrations training session and statements with reference to relevant experienced prob- What is the most effective way to structure a simulated lems and situations that occurred during the simulated team training session? Kolb’s learning cycle is currently event. This is an emotional phase and comparable to brain- the main conceptual framework used for experiential storming. Questions are asked and learners discuss different learning in simulation team training programmes [26-30]. views and aspects of a problem [26,29,31,32]. According to Kolb defines experiential learning as a process by which Kolb, these reflections are then assimilated and distilled into knowledge is created through the transformation of ex- abstract concepts from which new implications for action perience [31]. In this model, true learning is depicted as a can be drawn [31]. These new implications have to be four-part process in a cycle (Figure 1). Individuals learn actively tested and serve as guides in creating new ex- through concrete experience, reflection, conceptualisation, periences. This is the fourth phase of Kolb’s cycle (active and experimentation. The cycle begins with the learner’s experimentation). Figure 1 Kolb’s model of experiential learning. Stocker et al. BMC Medical Education 2014, 14:69 Page 3 of 9 http://www.biomedcentral.com/1472-6920/14/69 Debate 2: Simple experience versus experience of failure What do we know regarding the concrete experience as catalyst for effective learning? Kolb was not the only the- orist on experiential learning. Knowles defined andragogy and summarised adult learning principles as follows: Learning is most effective if we can relate to previous ex- periences, if we are internal motivated and if it is relevant and problem-centred [33]. Therefore it is mandatory to build scenarios with relevant problems to the participants. Scenarios can be derived from real events to obtain well- staged, realistic scenarios with clinical relevance and opti- mal authenticity [24]. This recommendation is in line with published frameworks and guidelines regarding simulated team training [13,19,30]. The debate regarding experience is focused on the level of difficulty and the importance of failure. One of Figure 2 Simulated team training in the conceptual framework the corner stones of Kolb’s learning cycle is the concept of Kolb’s experiential learning theory. of immediate individual experience as the basis of re- flective observation. In contrast, Miettinen elaborates that Dewey’s theory of reflective thought and action There is broad agreement regarding the first 3 phases regards not experience itself but the inadequacy and of Kolb’s learning cycle in published frameworks and contradictions of the habitual experience as the basis for guidelines how to structure a simulated training session. reflection [34]. This means, we are most motivated to However, the debate regarding structure is about the reflect and learn if we feel inadequate. The need to solve fourth phase (active experimentation). This part of the problems arising from habitual actions drives reflective cycle is often not executed during the same simulation observation, conceptualization and experimental activity session if programmes finish following the debriefing by to test new principles and ways. Published reviews re- summarising the conclusions drawn and the principles garding simulation in healthcare education are less expli- of the abstract conceptualizations [12,16,18,24,26,29,30]. cit regarding the level of difficulty, recommending that This means that active experimentation has to be com- training should be across a wide range of difficulty, com- pleted later, on an individual basis in the clinical setting, mencing at basic skills and proceeding progressively to or at another simulation session. According to Kolb, it is higher levels of difficulty [13,19]. However, if failure is important for learners to go through all four steps for preferable in order to initiate and drive the learning the learning to be effective [31]. There are three main process, training should be carefully targeted to the outcomes due to omission of this active experimentation needs of the participants. Each simulated event must phase: First, on an individual basis it may not be possible challenge team members by generating dissonance and for the learner to apply the concluded principles in a failures in order to optimise efficiency of simulated team safe environment, without facing the risk of real adverse training and adult learning. outcomes and reactions. Second, there is perhaps no Second Statement: It is mandatory to challenge partic- feedback of the environment to the newly applied action. ipants during simulated training to experience failures Both of these outcomes will discourage learners to apply and difficulties that serve as starting point for reflective a new, but not yet tested behaviour. Third, after a sub- observations. Scenarios derived from real events, pitched stantial time relapse, conceptualised but not tested to the learners’ background facilitate feelings of inad- changes may be lost. There is a real risk to return to equacy that motivate to learn: The group must feel that actions based on habits and non-reflective experience. they are operating at the edge of their comfort zone. Thus, active experimentation through experiencing a second scenario after debriefing is preferable. Debate 3: Individual reflection versus critical reflection in First Statement: An effective structure for a simulated the group team training session contains a scenario for concrete How should we reflect during debriefing in order to opti- experience, a debriefing with a reflexive observation and mise learning? Jarvis modified Kolb’s learning cycle and abstract conceptualisation phase, followed by a second developed a model with different possible ways taken in scenario for active experimentation. Let the learners go experiential learning situations [35]. Non-learning (learner back in after the debriefing even if for only a part of the does not respond to a specific learning situation), non- original scenario to try their new frames. reflective learning (memorisation or acquisition of manual Stocker et al. BMC Medical Education 2014, 14:69 Page 4 of 9 http://www.biomedcentral.com/1472-6920/14/69 skills without necessity of reflexion) and reflective learning situation, and to challenge their own conceptual frame- are possible end products. To minimise non-learning and works and principles. Participants need to feel secure in non-reflective learning it is essential that during the their group and motivated through their group members debriefing session facilitators incite and empower learners in order to challenge their own beliefs [27,34,37]. to go through the process of reflective observation and ab- Third Statement: Facilitate critical reflexion. Debrief- stract conceptualization. Conflict resolution between op- ing is fundamental and there is a need for participants posite principles and the integration of new, more precise to challenge their existing frameworks and principles. or refined ideas, are a process of adaptation and creating To support critical reflection trained facilitators and knowledge. There is broad agreement regarding the neces- peers are required to guide and motivate participants in sity of feedback and guided reflection after the simulated a secure and open way: Let the group talk and critical experience [13,16,19,26,27,29,30]. explore. This third debate questions the effectiveness of guided, individual critical reflection. In a recent published guide- Debate 4: Improvised versus real teams line regarding the use of reflection in medical education, The motivation and preparedness of participants to chal- Sandars elaborates educational strategies to develop re- lenge one’s own frameworks and principles may vary. Is flection: i) Motivation; ii) development of metacognitive it possible to enhance and activate this process within skills as noticing (through self-monitoring, feedback from real teams? According to Bandura, people’s judgements others, and analysis of significant events), processing (re- of their own ability to deal with different situations (self- flection for learning, to develop a therapeutic relationship, efficacy) is central to their actions [38]. He suggests that and to develop professional practice), and informing fu- motivation and self-knowledge are two main areas that ture action; and iii) reflective storytelling and writing [27]. play an important role in self-efficacy, and that this is Schön assumes that individuals live in a world of insecur- the major determinant of the goals a person will set, and ity, instability, complexity and conflict, where they often of the energy, effort, and perseverance that will be dedi- must deal with problems for which no existing rules or cated to their achievement. Self-efficacy may or may not theories learned through formal training can apply [36]. be accurate and arises from four main information Unexpected events, problems or surprises trigger two sources: Performance attainment, observation of other kinds of reflection. The first, “reflection-in-action”,occurs people, verbal persuasion, and physiological state [38,39]. immediately by improvising an “on the spot experimenta- The focus of this debate is the impact of using real teams tion”, thinking and testing out, refining and retesting versus improvised teams on the learning process in simu- various solutions for the problem. The second, “reflec- lated training. tion-on-action” occurs when individuals reflect after According to Bandura, observing what can happen the problem: They examine what they did, how they and drawing conclusions from experiences of others can did it and what alternatives existed [36]. Some of us re- also provide knowledge to the learner and influence self- flect in-action and share it with our teams at the time. efficacy [38]. Observation of others is not possible if All of us reflect-on-action but are usually not provided Kolb’s learning cycle is taken on an individual basis. with a system to share/process/learn from this reflec- However, a team training programme allows the possi- tion. Schön says that critical reflection is more than bility of observing others during the concrete experi- simply reflecting-in or reflecting-on-action, one’sown ence, followed by reflective observation and concrete conceptual framework must be questioned: why did I conceptualisation. Verbal persuasion occurs through do what I did? What beliefs inform my practice and feedback of other participants as well as observing how are these beliefs helping or hindering my work facilitators, during the reflective observation and con- [36]? Miettinen analysing Dewey’s theory of reflective crete conceptualisation phases of debriefing. Learning thought and action regards individual observations as is further enhanced when associated with a heightened laden by prior conceptualisation and interpretation physiological state (increased heart rate, sweating and [34]. Learners need strong guidance of one’speersand muscle tension) from scenario engagement. In order to facilitators to truly reflect on self. It is highly unlikely involve and challenge participants it is important to that an individual would beabletoobserve unbiased build realistic concrete experiences within real teams experiences, reflect openly on these, conceptualise new (i.e. high-fidelity mannequins, authentic scenarios ob- ideas and principles, and apply these new concepts ac- tained from real events, implementation of realistic tively, without the pressure of inadequacy and facilita- care as possible). To correctly pitch a scenario enab- tion through others [34]. Therefore it is important during ling physiologically activated participants to derive debriefing that participants explore and discuss their insight into their response to stress for improvised experience in depth within their group. They need to dis- teams is challenging due to previous unknown team ex- cover which form of adaptation works best in a particular pertise. In addition, interactions and feedback between Stocker et al. BMC Medical Education 2014, 14:69 Page 5 of 9 http://www.biomedcentral.com/1472-6920/14/69 team members with heightened physiological states may the social setting, and participation necessarily acts as a be much more pronounced within real teams than within disturbance to an already unstable system that offers improvised groups who may not know each other. Adopt- productive possibilities through change over time [45]. ing Bandura’s principles to simulation team training According to this model, a simulated team training ses- programmes, it is therefore essential to involve real sion can be thought of as an activity system. Key ques- multidisciplinary teams with members of different spe- tions during the session are then about the interplay of cialities and levels of expertise. As a team it is possible the different individuals, each with their different his- for the individual learner to observe peers, gain insight tory, role, dispositions and concerns. No individual mind into their own performance and to model behaviour is essential, but the distributed cognitive system with and knowledge [39]. Several publications investigating shared knowledge and skills. Significant changes in the the effect of resuscitation training demonstrated a system result not from individual decisions but from positive enhancement of self-efficacy through personal critical shifts in states of the system (team responding to performance mastery experience, observational learn- a crisis). To use a simulated event as an activity system ing, verbal persuasion and attention to the affective there is a need for real multidisciplinary teams with state of participants [40-42]. members of different expertise, acting in a standard set- Fourth Statement: Real team members of different up environment, with authentic and realistic events with specialities and levels of expertise support motivation clinical relevance. In this case, learning can be described and preparedness of participants for effective learning: as a system-based activity and the basic unit of analysis Make the gap between simulation and reality as small as is a functional team operating through time. Socio- possible. cultural learning theories therefore indicate that in-situ team training simulation sessions improve effectiveness Debate 5: Simulation centre versus in-situ simulation and efficacy of learning in preference to training in a Most studies reporting simulated team training are done simulation centre. in the setting of a simulation centre. Recently published Fifth Statement: It is mandatory to include the social guidelines and reviews regarding simulation based train- and cultural context of a team for effective team train- ing request a safe environment and an implementation ing. Real teams acting in their standard environment into a curriculum without specific discussion regarding (in-situ simulation) is the key to introduce context to the debate simulation setting [6,7,10,12-14,19]. The clas- the programme. sical learning theories and Kolb’s model have recently been criticized by Bleakley et al. because they refer to Conceptual framework the individual learner and not the team or system, and We have applied different models of experiential learn- so critical elements of learning are missed [43,44]. Bleak- ing theories, constructivism and of sociocultural theories ley advocates the use of socio-cultural learning models to create a conceptual framework for the design and de- in order to provide a more powerful tool for understand- livery of an optimal simulated team training programme ing how learning occurs in complex, dynamic systems (Figure 3). Our aim has been to outline different theories such as teams. The assumption that knowledge, mind illuminating different aspects of learning in simulated and memory are not just individual, but distributed team training and to combine these aspects to a concise across persons and artefacts, is one of the key points of and feasible framework (scholarship of integration and socio-cultural models: Knowledge is permanently negoti- application). There are also several recently published guide- ated by members of the team and common knowledge is lines and frameworks regardinglearningthrough simulation more than the sum of individual recollections [43]. In a using different strategies [4,12,13,18,19,21,30,46,47]. In order socio-cultural approach learners are not at the activity to investigate our work it is necessary to compare our new centre, they are just one aspect in a complex system conceptual framework with these published frameworks. where learning is sensitive to the context, and gaining Kneebone based his framework on his experience, access to activity is crucial. observations and on different learning theories [47]. He The most prominent theory expanding learning from used the model of Ericsson regarding deliberate practice acquisition to participation in dynamic social contexts is to emphasise gaining technical proficiency, Vygotsky’s the activity theory of Engeström [45]. An activity system “zone of proximal development” to illustrate the place of describes multiple actions of different people with a expert assistance, and Lave and Wenger to highlight the shared goal (the object). Each activity system should be importance of learning within a professional context. considered as a whole and goal-directed actions are Kneebone proposed 4 criteria to critically evaluate simu- always explicit or implicit, characterised by ambiguity, lation training: Simulation should i) allow for sustained, surprises, interpretations, sense making, and potential deliberate practice within a safe environment; ii) provide for change. The system is influenced and mediated by access to expert tutors; iii) map onto real life clinical Stocker et al. BMC Medical Education 2014, 14:69 Page 6 of 9 http://www.biomedcentral.com/1472-6920/14/69 statements. Feedback culture and a culture to change are important factors of the environment area of Zigmont’s framework [30]. We agree that these factors are mandatory for sustained change within a clinical environment. In-situ th th simulation with real teams (4 and 5 statements) may offer the possibility fostering organizational learning and culture change [49]. Berragan published a framework conceptualising learning through simulation based on sociocultural the- ories [46]. Benner and Sutphen’s concept of situated knowledge in practice and Engeström’s activity theory are used to explore learning during simulation. The focus of this framework is the formation of professional identity, contextualisation of care and development of professional competency. This framework based on th sociocultural learning theories is in line with our 4 and th 5 statements. Our framework, in addition, investigates Figure 3 Conceptual framework for effective simulated team training. the transfer of learning theories into practice as well as the principles of experiential learning and aspects on motivation and reflection. experience; and iv) provide a supportive, motivational, Cheng recently published a review for instructors regard- and learner-centred milieu. All these required principles ing simulation-based crisis resource management (CRM) are mapped to a certain extent in our framework. Delib- [18]. His guidelines are broadly based CRM-principles with erate praxis is essential for sustained change. This agrees description and appraisal of scenario design, debriefing with our first statement regarding the structure of the strategies and assessment tools. The described debriefing simulated team training. We focused on the structure of strategies are very similar supporting our first and third one training session requesting a second scenario to statements. The focus of assessment of teamwork during allow participants to experiment new applied frames. simulated team training is an aspect not covered in our For sustained improvement of team performance simu- framework. This is an omission due to our approach apply- lated team training should be embedded in a programme ing theories that are focused on learning and not assessing. thus enabling regular, repeated sessions [4,13,19,21,24]. Assessment is important for feedback and remediation [50] The request for access to expert tutors maps to our third and depends upon the content of the training session (i.e. statement: expert facilitators select an appropriate level CRM principles, technical skills) and available resources. of difficulty during the scenario and guide and empower Assessment tools for simulation training are not yet suffi- participants to critically reflect during the debriefing ciently validated or focused on teamwork [51]. Clearly, phase. This is in line with Kneebone’s criteria to provide assessment is mandatory for a teaching programme and a supportive, motivational and learner-centred milieu, a regular, longitudinal assessments may be a suitable ap- message supported as well by simulation studies outside proach with impact on learning and patient safety [52,53]. of the area of team training [48]. Our second and fifth Two recently published reviews regarding simulation statements encompass the criteria to map onto real life in healthcare education broadly support our first, second clinical experience, indeed we request more specifically and third statements [13,19]. Curriculum integration, to create experiences at the edge of the participants’ deliberate practice and assessment are aspects not suffi- comfort zone and within the clinical environment (in- ciently covered in our framework due to our focus on the situ simulation). single simulation session. Undoubtedly, it is mandatory to Zigmont used adult and experiential learning theories embed simulated team training into a teaching programme to propose a framework for developing and facilitating in order to enable repeated training and to therefore foster simulation courses [30]. For effective practice based optimal teamwork and patient safety [24]. In-situ simula- learning he focused on 3 areas: The individual (previous tion is a newer strategy with the advantage to be within the knowledge, self efficacy and psychological safety), the usual context and working environment. This provides an learning environment and key experiences. Within these opportunity to address organisational and system-based 3 areas he elaborated important principles as for ex- processes within the original cultural and social context ample key experiences have to be challenging, emotion- [21]. In our framework, emphasizing the sociocultural con- ally charged and contains mistakes and errors. These text (fourth and fifth statements) in simulated team train- principles are mapped to our second, third and fourth ing is probably the most significant difference to other Stocker et al. BMC Medical Education 2014, 14:69 Page 7 of 9 http://www.biomedcentral.com/1472-6920/14/69 published frameworks, and this may lead to better learning and motivate team members to critical reflect and learn. outcomes. The debate is regarding the importance of failure during There are several limitations of our proposed frame- the experience. The inadequacy and contradictions of work as developed through the application of learning the habitual experience (rather than the experience it- theories. The main limitation is the dependency on self) serve as a basis for reflection. A scenario generating learning theories without application and validation of dissonance and difficulties optimises the efficiency of the proposed framework. Reliability and validity of the simulated team training. framework have to be evaluated and the impact on Statement 3: Debriefing is fundamental to reflection learning needs to be compared to other published guide- on action and Schön’s theory is that there is a need for lines. Second, our framework is focused on a single participants to challenge their existing frameworks and simulation session. Published literature shows the neces- principles. Facilitators and peers must guide and motiv- sity of embedding simulated team training into a cur- ate participants through the debriefing session, inciting riculum with the possibility of repeated training and and empowering critical reflexion. To do this, learners deliberate practice. Third, assessment of team perform- need to feel psychological safe. The debate is regarding ance is mandatory for feedback and remediation and this the effectiveness of individual, critical reflexion. Individ- aspect is not covered within our framework. ual observations are laden by prior conceptualisation The strengths of our debate are the comparison and and interpretation and it is highly unlikely that an individ- discussion of diverse learning theories, their application ual learner is able to observe unbiased experience, reflect to simulated team training, the outcome of several state- critically challenging habitual frameworks and conceptual- ments describing the important aspects of a training ses- ise new principles. Use the impact of all group members sion and the conclusion with a concise and feasible to drive and motivate individual participants to challenge framework. their own beliefs. Statement 4: Bandura’s theory of self-efficacy proposes Summary that real multidisciplinary team members acting within There are several implications following the debate and their speciality and roles support motivation and pre- critical appraisal of relevant learning theories as a paredness of participants for effective learning. The de- conceptual framework for simulated team training pro- bate is regarding the impact of real compared to improvised grammes. There is always a gap between simulation and teams. Interactions between team members to heighten real clinical life. Simulation-based education can com- physiological state, to observe peers gaining insight into their plement, but should not replace education involving real own performance and to model behaviour may be much patients in genuine settings. Nevertheless, simulation more pronounced within real teams compared to impro- team training can serve as a powerful tool and environ- vised teams not knowing each other. Use real teams foster- ment for learning. To be fully effective it is important to ing and supporting preparedness and motivation to improve critically appraise the programme, to explicitly acknow- their own team performance. ledge and name the conceptual frameworks used and to Statement 5: Socio-cultural learning theory proposes compare them with known learning principles. that it is mandatory to introduce cultural context and Statement 1: Kolb’s experiential learning theory pre- social conditions to the learning experience for effective scribes mandatory steps for effective simulated team team training. The debate is regarding team training in a training sessions: Scenario for concrete experience, simulation centre versus in-situ simulation. Knowledge followed by a debriefing with a critical, reflexive observa- is permanently negotiated by members of a team and tion and abstract conceptualisation phase, and ending learners are just one aspect in a complex system where with a second scenario for active experimentation. Let learning is sensitive to the context. The system is influ- enced and mediated by the social setting and the con- the learners go back in after the debriefing even if for only a part of the original scenario to try their new text. Significant changes result not from individual frames. The debate is regarding the second scenario. decisions but from the team shifting in critical states during their response to a crisis. Use in-situ simulation Omission of the second experimentation phase means no possibility to apply new frames in a safe environment, to introduce the social and context setting into the train- no guaranteed feedback of new applied actions and after ing to improve effectiveness and efficacy of the learning session. substantial time relapse risk of losing conceptualised but not tested behaviours. Let them re-experiment to opti- We created a conceptual framework applying the 5 mise the effect of a simulated team training session. statements coming out of different learning theories. We compared our new framework with other published Statement 2: Other experiential learning theorists in- form us that the scenario needs to challenge participants frameworks and guidelines regarding simulated training. to generate failures and feelings of inadequacy to drive All statements are to some extent included in recently Stocker et al. BMC Medical Education 2014, 14:69 Page 8 of 9 http://www.biomedcentral.com/1472-6920/14/69 published guidelines and different frameworks, whereas 7. Marsch SC, Müller C, Marquardt K, Conrad G, Tschan F, Hunziker PR: Human factors affect the quality of cardiopulmonary resuscitation in simulated there is no publication referring to all 5 statements. In cardiac arrest. Resuscitation 2004, 60:51–6. contrast to others, our proposed framework emphasises 8. Morey JC, Simon R, Jay GD, Wears PL, Salisbury M, Dukes KA, Berns SD: the social setting and context together with the request Errors reduction and performance improvement in the emergency department through formal teamwork training. Evaluation results of the for real multidisciplinary teams emphasising in-situ MedTeams project. Health Serv Res 2002, 37:553–61. simulation for optimal team training. Curriculum inte- 9. 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Stocker M, Allen M, Pool N, De Costa K, Combes J, West N, Burmester M: Impact of an embedded simulation team training programme in a Received: 8 December 2013 Accepted: 28 March 2014 paediatric intensive care unit: a prospective, single-centre, longitudinal Published: 3 April 2014 study. Int Care Med 2012, 38:99–104. 25. Hodges BD, Kuper A: Theory and practice in the design and conduct of graduate medical education. Acad Med 2012, 87:25–33. References 26. Rudolph JW, Simon R, Raemer DB, Eppich WJ: Debriefing as formative 1. Accreditation Council for Graduate Medical Education. Common program assessment: Closing performance gaps in medical education. Acad Emerg requirements: General competencies. 2007 [http://www.acgme.org] Med 2008, 15:1010–6. 2. Frank JR (Ed): The CanMEDS 2005 physician competency framework. Better 27. Sandars J: The use of reflection in medical education. AMEE guide No. 44. standards. Better physicians. Better care. Ottawa,ON: Royal College of Med Teach 2009, 31:685–95. Physicians and Surgeons of Canada; 2005. 28. Yardley S, Teunissen PW, Dornan T: Experiential learning: AMEE guide No. 63. 3. General Medical Council: Tomorrow’s Doctors. Outcomes and standards for Med Teach 2012, 34:e102–15. undergraduate medical education. London: General Medical Council; 2009. 29. Zigmont JJ, Kappus LJ, Sudikoff SN: The 3D model of debriefing: Defusing, 4. Salas E, Rosen MA: Building high reliability teams: progress and some discovering, and deepening. Semin Perinatol 2011, 35:52–8. reflections on teamwork training. BMJ Qual Saf 2013, 22:369–73. 30. Zigmont JJ, Kappus LJ, Sudikoff SN: Theoretical foundations of learning 5. Anderson PO, Jensen MK, Lippert A, Ostergaard D: Identifying non-technical through simulation. Semin Perinatol 2011, 35:47–51. skills and barriers for improvement of teamwork in cardiac arrest teams. 31. Kolb DA: Experiential learning: Experience as the source of learning and Resuscitation 2010, 81:695–702. development. Englewood Cliffs, NJ: Prentice Hall; 1984. 6. Hunziker S, Tschan F, Semmer NK, Zobrist R, Spychiger M, Breuer M, Hunziker PR, Marsch SC: Hands-on time during cardiopulmonary 32. Rudolph JW, Simon R, Dufresne RL, Raemer DB: There’s no such thing as resuscitation is affected by the process of teambuilding: a prospective “nonjudgmental” debriefing: A theory and method for debriefing with randomised simulator-based trial. BMC Emerg Med 2009, 9:3. good judgment. Simul Healthcare 2006, 1:49–55. Stocker et al. BMC Medical Education 2014, 14:69 Page 9 of 9 http://www.biomedcentral.com/1472-6920/14/69 33. Knowles M: Andragogy in action. London: Jossey-Bass; 1985. 34. Miettinen R: The concept of experiential learning and John Dewey’s theory of reflective thought and action. Int J lifelong Edu 2000, 19(1):54–72. 35. Jarvis P: Adults as learners. 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Stocker M, Menadue L, Kakat S, De Costa K, Combes J, Banya W, Lane M, Desai A, Burmester M: Reliability of team-based self-monitoring in critical events: a pilot study. BMC Emergency Med 2013, 13:22. 53. Van der Vleuten CP, Schuwirth LW, Driessen EW, Dijkstra J, Tigelaar D, Baartman LK, Van Tartwijk J: A model for programmatic assessment fit for purpose. Med Teach 2012, 34:205–14. doi:10.1186/1472-6920-14-69 Cite this article as: Stocker et al.: Optimisation of simulated team training through the application of learning theories: a debate for a Submit your next manuscript to BioMed Central conceptual framework. 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Optimisation of simulated team training through the application of learning theories: a debate for a conceptual framework

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Copyright © 2014 by Stocker et al.; licensee BioMed Central Ltd.
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Education; Medical Education; Theory of Medicine/Bioethics
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Abstract

Background: As a conceptual review, this paper will debate relevant learning theories to inform the development, design and delivery of an effective educational programme for simulated team training relevant to health professionals. Discussion: Kolb’s experiential learning theory is used as the main conceptual framework to define the sequence of activities. Dewey’s theory of reflective thought and action, Jarvis modification of Kolb’s learning cycle and Schön’s reflection-on-action serve as a model to design scenarios for optimal concrete experience and debriefing for challenging participants’ beliefs and habits. Bandura’s theory of self-efficacy and newer socio-cultural learning models outline that for efficient team training, it is mandatory to introduce the social-cultural context of a team. Summary: The ideal simulated team training programme needs a scenario for concrete experience, followed by a debriefing with a critical reflexive observation andabstractconceptualisation phase, andendingwitha second scenario for active experimentation. Let them re-experiment to optimise the effect of a simulated training session. Challenge them to the edge: The scenario needs to challenge participants to generate failures and feelings of inadequacy to drive and motivate team members to critical reflect and learn. Not experience itself but the inadequacy and contradictions of habitual experience serve as basis for reflection. Facilitate critical reflection: Facilitators and group members must guide and motivate individual participants through the debriefing session, inciting and empowering learners to challenge their own beliefs and habits. To do this, learners need to feel psychological safe. Let the group talk and critical explore. Motivate with reality and context: Training with multidisciplinary team members, with different levels of expertise, acting in their usual environment (in-situ simulation) on physiological variables is mandatory to introduce cultural context and social conditions to the learning experience. Embedding in situ team training sessions into a teaching programme to enable repeated training and to assess regularly team performance is mandatory for a cultural change of sustained improvement of team performance and patient safety. Keywords: Teamwork, Team training, In-situ simulation, Experiential learning theory, Socio-cultural learning theories, Conceptual framework Background and teamwork) during critical events has repeatedly During the last decade medical and nursing authorities been shown to contribute to adverse events and poor and societies have increasingly recognised the critical patient outcomes [5-9]. The benefit of simulation train- importance of team training as a mandatory domain for ing for non-technical skills for critical events has been health professional education [1-4]. Suboptimal perform- shown in several studies to improve patient safety ance in non-technical skills (communication, leadership [10-16]. However, there is on-going debate as to which is the most effective way to provide simulation team training to health professionals [11-13,17-21]. * Correspondence: martin.stocker@luks.ch Individuals bring assumptions about themselves, others Neonatal and Paediatric Intensive Care Unit, Children’s Hospital Lucerne, and events to learning opportunities. These different views Spitalstrasse, Lucerne 16 CH-6000, Switzerland of reality are our personal “conceptual frameworks” [22]. Full list of author information is available at the end of the article © 2014 Stocker et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. 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. Stocker et al. BMC Medical Education 2014, 14:69 Page 2 of 9 http://www.biomedcentral.com/1472-6920/14/69 A debate with critical appraisal of conceptual frameworks involvement in a specific experience (such as doing or can lead educator and researcher to alternate views, with feeling); then they reflect on the experience from a variety potential impact on design or assessment of educational of perspectives (reflective observation such as examining programmes [22]. In a recent review of the literature or watching). Through reflection learners integrate their regarding experimental studies in medical education, only observations into more abstract models, create gener- half of the authors declared their conceptual frameworks alisations and principles and draw conclusions (abstract [23]. We have recently published our simulated team conceptualization such as explaining or thinking). The training programme, with no reference to the underlying individual then uses these principles and conclusions to conceptual framework [24]. Debating the educational guide subsequent decisions and actions (active experimen- framework underlying a simulation programme may tation such as applying or doing) that lead to new con- improve effectiveness, impact on team performance crete experiences [31]. and hence patient safety. Hodges has recently advo- According to Kolb’s four-stage experiential learning cated the use of bioscience, learning and sociocultural cycle, immediate and concrete experiences are the basis theories to design and conduct medical education pro- for observations and reflections [31]. Consequently all grammes [25]. The following discussion will explore participants in a simulated team training programme key educational frameworks and highlight aspects and need to begin by completing a simulated critical event debates that inform the development, design and deliv- (Figure 2). They then come together for structured ery of an effective educational programme for simu- debriefing [26,29,32]. Debriefing addresses the second and lated team training relevant to health professionals. third phases of Kolb’s cycle: reflective observation, then abstract conceptualization. Reflective observation de- Discussion scribes observation and analysis of a concrete experience. Debate 1: Single versus repeated exposure in one This is mainly characterized through participants’ narrations training session and statements with reference to relevant experienced prob- What is the most effective way to structure a simulated lems and situations that occurred during the simulated team training session? Kolb’s learning cycle is currently event. This is an emotional phase and comparable to brain- the main conceptual framework used for experiential storming. Questions are asked and learners discuss different learning in simulation team training programmes [26-30]. views and aspects of a problem [26,29,31,32]. According to Kolb defines experiential learning as a process by which Kolb, these reflections are then assimilated and distilled into knowledge is created through the transformation of ex- abstract concepts from which new implications for action perience [31]. In this model, true learning is depicted as a can be drawn [31]. These new implications have to be four-part process in a cycle (Figure 1). Individuals learn actively tested and serve as guides in creating new ex- through concrete experience, reflection, conceptualisation, periences. This is the fourth phase of Kolb’s cycle (active and experimentation. The cycle begins with the learner’s experimentation). Figure 1 Kolb’s model of experiential learning. Stocker et al. BMC Medical Education 2014, 14:69 Page 3 of 9 http://www.biomedcentral.com/1472-6920/14/69 Debate 2: Simple experience versus experience of failure What do we know regarding the concrete experience as catalyst for effective learning? Kolb was not the only the- orist on experiential learning. Knowles defined andragogy and summarised adult learning principles as follows: Learning is most effective if we can relate to previous ex- periences, if we are internal motivated and if it is relevant and problem-centred [33]. Therefore it is mandatory to build scenarios with relevant problems to the participants. Scenarios can be derived from real events to obtain well- staged, realistic scenarios with clinical relevance and opti- mal authenticity [24]. This recommendation is in line with published frameworks and guidelines regarding simulated team training [13,19,30]. The debate regarding experience is focused on the level of difficulty and the importance of failure. One of Figure 2 Simulated team training in the conceptual framework the corner stones of Kolb’s learning cycle is the concept of Kolb’s experiential learning theory. of immediate individual experience as the basis of re- flective observation. In contrast, Miettinen elaborates that Dewey’s theory of reflective thought and action There is broad agreement regarding the first 3 phases regards not experience itself but the inadequacy and of Kolb’s learning cycle in published frameworks and contradictions of the habitual experience as the basis for guidelines how to structure a simulated training session. reflection [34]. This means, we are most motivated to However, the debate regarding structure is about the reflect and learn if we feel inadequate. The need to solve fourth phase (active experimentation). This part of the problems arising from habitual actions drives reflective cycle is often not executed during the same simulation observation, conceptualization and experimental activity session if programmes finish following the debriefing by to test new principles and ways. Published reviews re- summarising the conclusions drawn and the principles garding simulation in healthcare education are less expli- of the abstract conceptualizations [12,16,18,24,26,29,30]. cit regarding the level of difficulty, recommending that This means that active experimentation has to be com- training should be across a wide range of difficulty, com- pleted later, on an individual basis in the clinical setting, mencing at basic skills and proceeding progressively to or at another simulation session. According to Kolb, it is higher levels of difficulty [13,19]. However, if failure is important for learners to go through all four steps for preferable in order to initiate and drive the learning the learning to be effective [31]. There are three main process, training should be carefully targeted to the outcomes due to omission of this active experimentation needs of the participants. Each simulated event must phase: First, on an individual basis it may not be possible challenge team members by generating dissonance and for the learner to apply the concluded principles in a failures in order to optimise efficiency of simulated team safe environment, without facing the risk of real adverse training and adult learning. outcomes and reactions. Second, there is perhaps no Second Statement: It is mandatory to challenge partic- feedback of the environment to the newly applied action. ipants during simulated training to experience failures Both of these outcomes will discourage learners to apply and difficulties that serve as starting point for reflective a new, but not yet tested behaviour. Third, after a sub- observations. Scenarios derived from real events, pitched stantial time relapse, conceptualised but not tested to the learners’ background facilitate feelings of inad- changes may be lost. There is a real risk to return to equacy that motivate to learn: The group must feel that actions based on habits and non-reflective experience. they are operating at the edge of their comfort zone. Thus, active experimentation through experiencing a second scenario after debriefing is preferable. Debate 3: Individual reflection versus critical reflection in First Statement: An effective structure for a simulated the group team training session contains a scenario for concrete How should we reflect during debriefing in order to opti- experience, a debriefing with a reflexive observation and mise learning? Jarvis modified Kolb’s learning cycle and abstract conceptualisation phase, followed by a second developed a model with different possible ways taken in scenario for active experimentation. Let the learners go experiential learning situations [35]. Non-learning (learner back in after the debriefing even if for only a part of the does not respond to a specific learning situation), non- original scenario to try their new frames. reflective learning (memorisation or acquisition of manual Stocker et al. BMC Medical Education 2014, 14:69 Page 4 of 9 http://www.biomedcentral.com/1472-6920/14/69 skills without necessity of reflexion) and reflective learning situation, and to challenge their own conceptual frame- are possible end products. To minimise non-learning and works and principles. Participants need to feel secure in non-reflective learning it is essential that during the their group and motivated through their group members debriefing session facilitators incite and empower learners in order to challenge their own beliefs [27,34,37]. to go through the process of reflective observation and ab- Third Statement: Facilitate critical reflexion. Debrief- stract conceptualization. Conflict resolution between op- ing is fundamental and there is a need for participants posite principles and the integration of new, more precise to challenge their existing frameworks and principles. or refined ideas, are a process of adaptation and creating To support critical reflection trained facilitators and knowledge. There is broad agreement regarding the neces- peers are required to guide and motivate participants in sity of feedback and guided reflection after the simulated a secure and open way: Let the group talk and critical experience [13,16,19,26,27,29,30]. explore. This third debate questions the effectiveness of guided, individual critical reflection. In a recent published guide- Debate 4: Improvised versus real teams line regarding the use of reflection in medical education, The motivation and preparedness of participants to chal- Sandars elaborates educational strategies to develop re- lenge one’s own frameworks and principles may vary. Is flection: i) Motivation; ii) development of metacognitive it possible to enhance and activate this process within skills as noticing (through self-monitoring, feedback from real teams? According to Bandura, people’s judgements others, and analysis of significant events), processing (re- of their own ability to deal with different situations (self- flection for learning, to develop a therapeutic relationship, efficacy) is central to their actions [38]. He suggests that and to develop professional practice), and informing fu- motivation and self-knowledge are two main areas that ture action; and iii) reflective storytelling and writing [27]. play an important role in self-efficacy, and that this is Schön assumes that individuals live in a world of insecur- the major determinant of the goals a person will set, and ity, instability, complexity and conflict, where they often of the energy, effort, and perseverance that will be dedi- must deal with problems for which no existing rules or cated to their achievement. Self-efficacy may or may not theories learned through formal training can apply [36]. be accurate and arises from four main information Unexpected events, problems or surprises trigger two sources: Performance attainment, observation of other kinds of reflection. The first, “reflection-in-action”,occurs people, verbal persuasion, and physiological state [38,39]. immediately by improvising an “on the spot experimenta- The focus of this debate is the impact of using real teams tion”, thinking and testing out, refining and retesting versus improvised teams on the learning process in simu- various solutions for the problem. The second, “reflec- lated training. tion-on-action” occurs when individuals reflect after According to Bandura, observing what can happen the problem: They examine what they did, how they and drawing conclusions from experiences of others can did it and what alternatives existed [36]. Some of us re- also provide knowledge to the learner and influence self- flect in-action and share it with our teams at the time. efficacy [38]. Observation of others is not possible if All of us reflect-on-action but are usually not provided Kolb’s learning cycle is taken on an individual basis. with a system to share/process/learn from this reflec- However, a team training programme allows the possi- tion. Schön says that critical reflection is more than bility of observing others during the concrete experi- simply reflecting-in or reflecting-on-action, one’sown ence, followed by reflective observation and concrete conceptual framework must be questioned: why did I conceptualisation. Verbal persuasion occurs through do what I did? What beliefs inform my practice and feedback of other participants as well as observing how are these beliefs helping or hindering my work facilitators, during the reflective observation and con- [36]? Miettinen analysing Dewey’s theory of reflective crete conceptualisation phases of debriefing. Learning thought and action regards individual observations as is further enhanced when associated with a heightened laden by prior conceptualisation and interpretation physiological state (increased heart rate, sweating and [34]. Learners need strong guidance of one’speersand muscle tension) from scenario engagement. In order to facilitators to truly reflect on self. It is highly unlikely involve and challenge participants it is important to that an individual would beabletoobserve unbiased build realistic concrete experiences within real teams experiences, reflect openly on these, conceptualise new (i.e. high-fidelity mannequins, authentic scenarios ob- ideas and principles, and apply these new concepts ac- tained from real events, implementation of realistic tively, without the pressure of inadequacy and facilita- care as possible). To correctly pitch a scenario enab- tion through others [34]. Therefore it is important during ling physiologically activated participants to derive debriefing that participants explore and discuss their insight into their response to stress for improvised experience in depth within their group. They need to dis- teams is challenging due to previous unknown team ex- cover which form of adaptation works best in a particular pertise. In addition, interactions and feedback between Stocker et al. BMC Medical Education 2014, 14:69 Page 5 of 9 http://www.biomedcentral.com/1472-6920/14/69 team members with heightened physiological states may the social setting, and participation necessarily acts as a be much more pronounced within real teams than within disturbance to an already unstable system that offers improvised groups who may not know each other. Adopt- productive possibilities through change over time [45]. ing Bandura’s principles to simulation team training According to this model, a simulated team training ses- programmes, it is therefore essential to involve real sion can be thought of as an activity system. Key ques- multidisciplinary teams with members of different spe- tions during the session are then about the interplay of cialities and levels of expertise. As a team it is possible the different individuals, each with their different his- for the individual learner to observe peers, gain insight tory, role, dispositions and concerns. No individual mind into their own performance and to model behaviour is essential, but the distributed cognitive system with and knowledge [39]. Several publications investigating shared knowledge and skills. Significant changes in the the effect of resuscitation training demonstrated a system result not from individual decisions but from positive enhancement of self-efficacy through personal critical shifts in states of the system (team responding to performance mastery experience, observational learn- a crisis). To use a simulated event as an activity system ing, verbal persuasion and attention to the affective there is a need for real multidisciplinary teams with state of participants [40-42]. members of different expertise, acting in a standard set- Fourth Statement: Real team members of different up environment, with authentic and realistic events with specialities and levels of expertise support motivation clinical relevance. In this case, learning can be described and preparedness of participants for effective learning: as a system-based activity and the basic unit of analysis Make the gap between simulation and reality as small as is a functional team operating through time. Socio- possible. cultural learning theories therefore indicate that in-situ team training simulation sessions improve effectiveness Debate 5: Simulation centre versus in-situ simulation and efficacy of learning in preference to training in a Most studies reporting simulated team training are done simulation centre. in the setting of a simulation centre. Recently published Fifth Statement: It is mandatory to include the social guidelines and reviews regarding simulation based train- and cultural context of a team for effective team train- ing request a safe environment and an implementation ing. Real teams acting in their standard environment into a curriculum without specific discussion regarding (in-situ simulation) is the key to introduce context to the debate simulation setting [6,7,10,12-14,19]. The clas- the programme. sical learning theories and Kolb’s model have recently been criticized by Bleakley et al. because they refer to Conceptual framework the individual learner and not the team or system, and We have applied different models of experiential learn- so critical elements of learning are missed [43,44]. Bleak- ing theories, constructivism and of sociocultural theories ley advocates the use of socio-cultural learning models to create a conceptual framework for the design and de- in order to provide a more powerful tool for understand- livery of an optimal simulated team training programme ing how learning occurs in complex, dynamic systems (Figure 3). Our aim has been to outline different theories such as teams. The assumption that knowledge, mind illuminating different aspects of learning in simulated and memory are not just individual, but distributed team training and to combine these aspects to a concise across persons and artefacts, is one of the key points of and feasible framework (scholarship of integration and socio-cultural models: Knowledge is permanently negoti- application). There are also several recently published guide- ated by members of the team and common knowledge is lines and frameworks regardinglearningthrough simulation more than the sum of individual recollections [43]. In a using different strategies [4,12,13,18,19,21,30,46,47]. In order socio-cultural approach learners are not at the activity to investigate our work it is necessary to compare our new centre, they are just one aspect in a complex system conceptual framework with these published frameworks. where learning is sensitive to the context, and gaining Kneebone based his framework on his experience, access to activity is crucial. observations and on different learning theories [47]. He The most prominent theory expanding learning from used the model of Ericsson regarding deliberate practice acquisition to participation in dynamic social contexts is to emphasise gaining technical proficiency, Vygotsky’s the activity theory of Engeström [45]. An activity system “zone of proximal development” to illustrate the place of describes multiple actions of different people with a expert assistance, and Lave and Wenger to highlight the shared goal (the object). Each activity system should be importance of learning within a professional context. considered as a whole and goal-directed actions are Kneebone proposed 4 criteria to critically evaluate simu- always explicit or implicit, characterised by ambiguity, lation training: Simulation should i) allow for sustained, surprises, interpretations, sense making, and potential deliberate practice within a safe environment; ii) provide for change. The system is influenced and mediated by access to expert tutors; iii) map onto real life clinical Stocker et al. BMC Medical Education 2014, 14:69 Page 6 of 9 http://www.biomedcentral.com/1472-6920/14/69 statements. Feedback culture and a culture to change are important factors of the environment area of Zigmont’s framework [30]. We agree that these factors are mandatory for sustained change within a clinical environment. In-situ th th simulation with real teams (4 and 5 statements) may offer the possibility fostering organizational learning and culture change [49]. Berragan published a framework conceptualising learning through simulation based on sociocultural the- ories [46]. Benner and Sutphen’s concept of situated knowledge in practice and Engeström’s activity theory are used to explore learning during simulation. The focus of this framework is the formation of professional identity, contextualisation of care and development of professional competency. This framework based on th sociocultural learning theories is in line with our 4 and th 5 statements. Our framework, in addition, investigates Figure 3 Conceptual framework for effective simulated team training. the transfer of learning theories into practice as well as the principles of experiential learning and aspects on motivation and reflection. experience; and iv) provide a supportive, motivational, Cheng recently published a review for instructors regard- and learner-centred milieu. All these required principles ing simulation-based crisis resource management (CRM) are mapped to a certain extent in our framework. Delib- [18]. His guidelines are broadly based CRM-principles with erate praxis is essential for sustained change. This agrees description and appraisal of scenario design, debriefing with our first statement regarding the structure of the strategies and assessment tools. The described debriefing simulated team training. We focused on the structure of strategies are very similar supporting our first and third one training session requesting a second scenario to statements. The focus of assessment of teamwork during allow participants to experiment new applied frames. simulated team training is an aspect not covered in our For sustained improvement of team performance simu- framework. This is an omission due to our approach apply- lated team training should be embedded in a programme ing theories that are focused on learning and not assessing. thus enabling regular, repeated sessions [4,13,19,21,24]. Assessment is important for feedback and remediation [50] The request for access to expert tutors maps to our third and depends upon the content of the training session (i.e. statement: expert facilitators select an appropriate level CRM principles, technical skills) and available resources. of difficulty during the scenario and guide and empower Assessment tools for simulation training are not yet suffi- participants to critically reflect during the debriefing ciently validated or focused on teamwork [51]. Clearly, phase. This is in line with Kneebone’s criteria to provide assessment is mandatory for a teaching programme and a supportive, motivational and learner-centred milieu, a regular, longitudinal assessments may be a suitable ap- message supported as well by simulation studies outside proach with impact on learning and patient safety [52,53]. of the area of team training [48]. Our second and fifth Two recently published reviews regarding simulation statements encompass the criteria to map onto real life in healthcare education broadly support our first, second clinical experience, indeed we request more specifically and third statements [13,19]. Curriculum integration, to create experiences at the edge of the participants’ deliberate practice and assessment are aspects not suffi- comfort zone and within the clinical environment (in- ciently covered in our framework due to our focus on the situ simulation). single simulation session. Undoubtedly, it is mandatory to Zigmont used adult and experiential learning theories embed simulated team training into a teaching programme to propose a framework for developing and facilitating in order to enable repeated training and to therefore foster simulation courses [30]. For effective practice based optimal teamwork and patient safety [24]. In-situ simula- learning he focused on 3 areas: The individual (previous tion is a newer strategy with the advantage to be within the knowledge, self efficacy and psychological safety), the usual context and working environment. This provides an learning environment and key experiences. Within these opportunity to address organisational and system-based 3 areas he elaborated important principles as for ex- processes within the original cultural and social context ample key experiences have to be challenging, emotion- [21]. In our framework, emphasizing the sociocultural con- ally charged and contains mistakes and errors. These text (fourth and fifth statements) in simulated team train- principles are mapped to our second, third and fourth ing is probably the most significant difference to other Stocker et al. BMC Medical Education 2014, 14:69 Page 7 of 9 http://www.biomedcentral.com/1472-6920/14/69 published frameworks, and this may lead to better learning and motivate team members to critical reflect and learn. outcomes. The debate is regarding the importance of failure during There are several limitations of our proposed frame- the experience. The inadequacy and contradictions of work as developed through the application of learning the habitual experience (rather than the experience it- theories. The main limitation is the dependency on self) serve as a basis for reflection. A scenario generating learning theories without application and validation of dissonance and difficulties optimises the efficiency of the proposed framework. Reliability and validity of the simulated team training. framework have to be evaluated and the impact on Statement 3: Debriefing is fundamental to reflection learning needs to be compared to other published guide- on action and Schön’s theory is that there is a need for lines. Second, our framework is focused on a single participants to challenge their existing frameworks and simulation session. Published literature shows the neces- principles. Facilitators and peers must guide and motiv- sity of embedding simulated team training into a cur- ate participants through the debriefing session, inciting riculum with the possibility of repeated training and and empowering critical reflexion. To do this, learners deliberate practice. Third, assessment of team perform- need to feel psychological safe. The debate is regarding ance is mandatory for feedback and remediation and this the effectiveness of individual, critical reflexion. Individ- aspect is not covered within our framework. ual observations are laden by prior conceptualisation The strengths of our debate are the comparison and and interpretation and it is highly unlikely that an individ- discussion of diverse learning theories, their application ual learner is able to observe unbiased experience, reflect to simulated team training, the outcome of several state- critically challenging habitual frameworks and conceptual- ments describing the important aspects of a training ses- ise new principles. Use the impact of all group members sion and the conclusion with a concise and feasible to drive and motivate individual participants to challenge framework. their own beliefs. Statement 4: Bandura’s theory of self-efficacy proposes Summary that real multidisciplinary team members acting within There are several implications following the debate and their speciality and roles support motivation and pre- critical appraisal of relevant learning theories as a paredness of participants for effective learning. The de- conceptual framework for simulated team training pro- bate is regarding the impact of real compared to improvised grammes. There is always a gap between simulation and teams. Interactions between team members to heighten real clinical life. Simulation-based education can com- physiological state, to observe peers gaining insight into their plement, but should not replace education involving real own performance and to model behaviour may be much patients in genuine settings. Nevertheless, simulation more pronounced within real teams compared to impro- team training can serve as a powerful tool and environ- vised teams not knowing each other. Use real teams foster- ment for learning. To be fully effective it is important to ing and supporting preparedness and motivation to improve critically appraise the programme, to explicitly acknow- their own team performance. ledge and name the conceptual frameworks used and to Statement 5: Socio-cultural learning theory proposes compare them with known learning principles. that it is mandatory to introduce cultural context and Statement 1: Kolb’s experiential learning theory pre- social conditions to the learning experience for effective scribes mandatory steps for effective simulated team team training. The debate is regarding team training in a training sessions: Scenario for concrete experience, simulation centre versus in-situ simulation. Knowledge followed by a debriefing with a critical, reflexive observa- is permanently negotiated by members of a team and tion and abstract conceptualisation phase, and ending learners are just one aspect in a complex system where with a second scenario for active experimentation. Let learning is sensitive to the context. The system is influ- enced and mediated by the social setting and the con- the learners go back in after the debriefing even if for only a part of the original scenario to try their new text. Significant changes result not from individual frames. The debate is regarding the second scenario. decisions but from the team shifting in critical states during their response to a crisis. Use in-situ simulation Omission of the second experimentation phase means no possibility to apply new frames in a safe environment, to introduce the social and context setting into the train- no guaranteed feedback of new applied actions and after ing to improve effectiveness and efficacy of the learning session. substantial time relapse risk of losing conceptualised but not tested behaviours. Let them re-experiment to opti- We created a conceptual framework applying the 5 mise the effect of a simulated team training session. statements coming out of different learning theories. We compared our new framework with other published Statement 2: Other experiential learning theorists in- form us that the scenario needs to challenge participants frameworks and guidelines regarding simulated training. to generate failures and feelings of inadequacy to drive All statements are to some extent included in recently Stocker et al. BMC Medical Education 2014, 14:69 Page 8 of 9 http://www.biomedcentral.com/1472-6920/14/69 published guidelines and different frameworks, whereas 7. Marsch SC, Müller C, Marquardt K, Conrad G, Tschan F, Hunziker PR: Human factors affect the quality of cardiopulmonary resuscitation in simulated there is no publication referring to all 5 statements. In cardiac arrest. Resuscitation 2004, 60:51–6. contrast to others, our proposed framework emphasises 8. Morey JC, Simon R, Jay GD, Wears PL, Salisbury M, Dukes KA, Berns SD: the social setting and context together with the request Errors reduction and performance improvement in the emergency department through formal teamwork training. Evaluation results of the for real multidisciplinary teams emphasising in-situ MedTeams project. Health Serv Res 2002, 37:553–61. simulation for optimal team training. Curriculum inte- 9. 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