Previously Developed Pedagogical Models for Simulation-based

Kolb’s (1984) experiential learning theory is the most widely-used education-al theory that has been applied to understand and orchestrate the teaching and learning processes in simulation-based learning environments (Anderson, Aylor

& Leonard, 2008; Craft, Feldon & Brown, 2014; Poore, Cullen & Schaar, 2014;

Zigmont et al., 2011a; Wang, 2011). In experiential learning, experiences – either simulated or real – provide the catalyst for learning. Learning is attained when the learner reflects on and transforms the experiences into knowledge that is usable in future practice (Kolb, 1984). From Kolb’s (1984) perspective, learning is holistic and a life-long process, where “all learning is relearning.”

Kolb (1984) created a learning cycle that involves four phases: 1) concrete experi-ence is the phase in which the learner participates in an experiexperi-ence, such as simula-tion; 2) then the learner reflects on that experience (reflective observation); 3) after experiencing and reflecting, the individual is able to think logically about the situ-ation, and accommodate or shape his or her mental model into a more coherent theory (abstract conceptualization); and 4) finally, the learner is ready to test this theory in a new simulation or in real life (active experimentation). In the field of simulation-based healthcare and medical education, it is commonly thought that concrete experience is the phase in which the learners participate in the simula-tion; thereafter, they reflect on and conceptualize the experience during the de-briefing phase; and in an ideal situation, they can test their newly formed theories in real life or in a new simulation scenario (Zigmont et al., 2011b).

In recent years, researchers have developed more specific models of how to or-chestrate simulation-based learning, either in general applications or specifically in the field of healthcare education. Both the Learning through simulation model (Joyce et al., 2002) and the Simulation setting model (Dieckmann, 2009b) have influenced the development of the model presented in this dissertation. Dieck-mann’s (2009b) model is specifically intended for simulation-based healthcare ed-ucation, whereas Joyce et al. (2002) created a general model for simulation-based education. However, these two models have a great deal in common, and therefore I have taken both of them into consideration when developing the pedagogical model for simulation-based learning in healthcare. Both models include the fol-lowing four phases: (1) introduction, (2) simulator briefing, (3) scenarios, and (4) debriefing (Dieckmann, 2009b; Joyce et al., 2002). I see these as the main phases, and I have embedded them in the pedagogical model. As noted earlier, these phas-es are also congruent with Kolb’s (1984) experiential learning cycle. Dieckmann’s (2009) model includes three additional phases, namely Theory, Scenario briefing,

and Course ending. The Scenario briefing and Course ending phases are usually pres-ent in simulation-based courses, although I do not refer to them as such in the pedagogical model. However, Dieckmann and others (2012) have also stated that their model is flexible in nature since the number and order of the phases can vary.

Most researchers agree that simulation-based education starts with the introduc-tion. It is often stated that the most important goal for this phase is the creation of a safe and non-threatening atmosphere (Boese et al., 2013; Clapper, 2010; Di-eckmann, 2009b; Dieckmann et al., 2012; Wang, 2011; Zigmont et al., 2011a), as participating in a simulation can be stressful (Brewer, 2011; Weller, 2004). A suc-cessful introductory phase sets ground rules, creates an initial and joint knowledge base and a positive atmosphere, as well as creating the script and schedule for the upcoming learning event (Dieckmann et al., 2012).

During the simulator and scenario briefing phases, participants get to know the physical environment and the case that will be handled. It is good for the partici-pants to be aware of what is considered normal in the simulator compared to what is normal in a real patient. Therefore, hands-on time is important in this phase (Dieckmann, 2009b). Scenarios are the phase in which the students take the lead-ing role when practiclead-ing with and in the SBLE. From the viewpoint of learnlead-ing theory, in this phase learners have a chance to use the knowledge and skills of a discipline in order to understand things more deeply (Laurillard, 2012). During this phase, the facilitator’s role is to remain on the sidelines and monitor the par-ticipants’ behavior.

Debriefing is the final phase of simulation-based education, and it is often stated that it is the most important phase of simulation-based education (Wang, 2011), since this is the phase when students can review and reflect on their learning and identify potential knowledge gaps. Studies have proposed different models for conducting the debriefing phase (Dreifuerst, 2012; Dufrene & Young, 2014;

Fanning & Gaba, 2007; Rudolph et al., 2007; Steinwachs, 1992; Zigmont et al., 2011b), although there is currently no clear evidence that one particular method is better than any other (Dufrene & Young, 2014). However, there is undisputable evidence that feedback is essential for enhancing the learning (Issenberg et al., 2005; Norman & Schmidt, 1992) and the expertise (Ericsson, Krampe & Tesch-Römer, 1993).The basic goal of the debriefing is for the participants to review their understanding and skills as well as formulate new learning objectives (Ru-dolph et al., 2007). According to Ru(Ru-dolph et al. (2007, p. 361), the goals and pro-cesses of the debriefing are:

…to allow trainees to explain, analyze, and synthesize information and emotional states to improve performance in similar situations in the future.

The process for achieving these goals usually follows a series of steps, such

as processing reactions, analyzing the situation, generalizing to everyday ex-perience, and shaping future actions by lessons learned.

Steinwachs (1992) has proposed a three-phase model of debriefing, which is quite typical in simulation-based education (see also Konia & Yao, 2013). The first phase is the description phase, where the learners basically describe what has hap-pened and share their first impressions and feelings about the scenario. As Dieck-mann (2009b) points out, a typical question in this phase is “What happened?” In the next phase, the analysis phase, the participants go deeper into the scenario and figure out the causes and reasons for their decisions and actions. The goal of this phase is to help participants figure out why they acted as they did, and how they can change their mental models in order to behave differently next time, if needed.

The application phase is when the learners consider what they can take home from the learning experience and what things can be transferred into clinical practice.

To summarize the main points of this chapter, simulation-based learning is usually grounded in the ideas of andragogy, experiential learning and socio-cul-tural theory. Researchers and practitioners also agree that there are at least four phases that are essential in simulation-based learning. However, as I mentioned earlier, we should consider learning from multiple and multidisciplinary perspec-tives, which, I think, gives a more complete view of the phenomenon. In this ap-proach, the lens of socio-cultural theory and meaningful learning is useful.