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How Cultural-Historical Activity Theory can Inform Interprofessional Team Debriefings
Abstract
Culturalehistorical activity theory (CHAT) foregrounds context in work activities and provides simulation educators a valuable lens to view simulations and debriefings. CHAT offers a complementary conceptual framework when used in conjunction with established debriefing strategies. CHAT focuses attention on work activities as goal-directed social encounters and makes the activity system the basic unit of analysis. Activity systems include the individual(s) involved, their objective(s), and the tools/mediating artifacts used to achieve those objectives within contexts that contain rules,ncommunities, and clear divisions of labor. CHAT may help simulation educators in a number of ways: (a) to reframe how they observe and interpret complex social interactions within team simulations, (b) to help identify and prioritize topics for debriefing, (c) to explore contextual factors promoting or impeding safe and effective patient care, and (d) to facilitate discussion beyond lessons from the concrete simulation event to generalize learning to future clinical practice.
... Activity Theory was discussed in the context of simulation practice (Eppich and Cheng 2015b) and is a promising approach to structured debriefings. Activity Theory underlines what motives simulation participants followed during the scenario and what concrete goals they tried to achieve. ...
... Activity Theory underlines what motives simulation participants followed during the scenario and what concrete goals they tried to achieve. It helps describe how those involved interacted with each other, with the environment, and how they used tools, distributed work, etc. (Eppich and Cheng 2015b). ...
... Culture is a concept with a great deal of face value but is also a difficult concept to define and quantify. Unlike in the airline industry literature, little research in healthcare has focused on the cultural perspective of learning and simulation [10][11][12][13] or on the effect of culture on adverse events. 6,10,14 In this article, we focus on national cultures, as opposed to, for instance, professional or organizational cultures. ...
... Unlike in the airline industry literature, little research in healthcare has focused on the cultural perspective of learning and simulation [10][11][12][13] or on the effect of culture on adverse events. 6,10,14 In this article, we focus on national cultures, as opposed to, for instance, professional or organizational cultures. ...
Introduction:
Culture is believed to play a role in education, safety, and patient outcome in healthcare. Hofstede's culture analysis permits a quantitative comparison between countries, along different culture dimensions, including power distance (PD). Power distance index (PDI) is a value reflecting social hierarchy in a country. We sought to explore the relation between PDI and self-reported behavior patterns of debriefers during simulation debriefings. We determined six culture-relevant debriefing characteristics and formulated six hypotheses on how these characteristics correlate with national PDIs.
Methods:
Low-PDI countries have a PDI of 50 or less, and high-PDI countries have a PDI of 51 or greater as defined by Hofstede. Interviews with simulation debriefers were used to investigate culture-relevant debriefing characteristics: debriefer/participant talking time, debriefer/participant interaction pattern, debriefer/participant interaction style, debriefer/participant initiative for interactions, debriefing content, and difficulty with which nontechnical skills can be discussed.
Results:
During debriefing, in low-PDI countries, debriefers talked less and used more open-ended questions and focused more on nontechnical issues than on medical knowledge and simulation participants initiated most interactions. In low-PDI countries, debriefers felt that participants interacted more with each other and found it easier to address nontechnical skills such as speaking-up.
Conclusions:
Our results supported our hypotheses. National culture is related to debriefing practice. There is a clear relation between PDI and debriefer-participant behavior patterns as described by debriefers. The higher the PDI of a country, the more the debriefer determines the course of the debriefing and the more difficult it becomes to address nontechnical skills.
... Using debriefing strategies that incorporate cultural-history activity theory to bridge the sociocultural differences in rules, norms, and customs between interprofessional team members may be a useful approach (Eppich and Cheng, 2015). ...
The concept of high-functioning healthcare teams is complex and competencies have been developed primarily from aviation. High-functioning healthcare teams, including those formed in an ad-hoc manner, are crucial to positive patient outcomes. Social capital theory identifies structural, cognitive and relational dimensions involved in the formation of trusting, cohesive relationships. Theories of social capital can be used to advise the development of interprofessional simulation-based education. Interprofessional simulation-based education curricula development must focus on the social sciences if it is to promote strong, healthy team relationships. Simulation-based education should take place in learning environments that promote the development of social capital between team members, especially where teams are formed ad hoc.
... Using debriefing strategies that incorporate cultural-history activity theory to bridge the sociocultural differences in rules, norms, and customs between interprofessional team members may be a useful approach (Eppich and Cheng, 2015). ...
The concept of high functioning healthcare teams is complex and competencies have been developed primarily from aviation. High-functioning healthcare teams, including those formed in an ad-hoc manner, are crucial to positive patient outcomes. Social capital theory identifies structural, cognitive and relational dimensions involved in the formation of trusting, cohesive relationships. Theories of social capital can be used to advise the development of interprofessional simulation-based education. Interprofessional simulation-based education curricula development must focus on the social sciences if it is to promote strong, healthy team relationships. Simulation-based education should take place in learning environments that promote the development of social capital between team members, especially where teams are formed ad hoc.
... Social constructionism has strongly influenced SBE, through the notion of subjective and collective construction of meaning, and the role of community and social context in learning (33)(34)(35)(36). Other approaches, such as Cultural-Historical Activity Theory, further emphasised historical and cultural contexts that shape the group elaboration of meaning (37), while others still have helped to describe how SBE can challenge participants' assumptions and beliefs towards patients with mental disorders, for example transformative learning theory (38). ...
Despite recognised benefits of Simulation-Based Education (SBE) in healthcare, specific adaptations required within psychiatry have slowed its adoption. This article aims to discuss conceptual and practical features of SBE in psychiatry that may support or limit its development, so as to encourage clinicians and educators to consider the implementation of SBE in their practice. SBE took off with the aviation industry and has been steadily adopted in clinical education, alongside role play and patient educators, across many medical specialities. Concurrently, healthcare has shifted towards patient-centred approaches and clinical education has recognised the importance of reflective learning and teaching centred on learners' experiences. SBE is particularly well-suited to promoting a holistic approach to care, reflective learning, emotional awareness in interactions and learning, cognitive reframing, and co-construction of knowledge. These features present an opportunity to enhance education throughout the healthcare workforce, and align particularly well to psychiatric education, where interpersonal and relational dimensions are at the core of clinical skills. Additionally, SBE provides a strategic opportunity for people with lived experience of mental disorders to be directly involved in clinical education. However, tenacious controversies have questioned the adequacy of SBE in the psychiatric field, possibly limiting its adoption. The ability of simulated patients (SPs) to portray complex and contradictory cognitive, psychological and emotional states has been questioned. The validity of SBE to develop a genuine empathetic understanding of patients, to facilitate a comprehensive multiaxial diagnostic formulation, or to develop flexible interpersonal skills has been criticised. Finally, SBE's relevance to developing complex psychotherapeutic skills is much debated, while issues such as symptom induction in SPs or patients involvement raise ethical dilemmas. These controversies can be addressed through adequate evidence, robust learning design, and high standards of practice. Well-designed simulated scenarios can promote a positive consideration of mental disorders and complex clinical skills. Shared guidelines and scenario libraries for simulation can be developed, with expert psychiatrists, patients and students involvement, to offer SPs and educators a solid foundation to develop training. Beyond scenario design, the nuances and complexities in mental healthcare are also duly acknowledged during the debriefing phases, providing a crucial opportunity to reflect on complex interpersonal skills or the role of emotions in clinicians' behaviour. Considered recruitment and support of SPs by clinical educators can help to maintain psychological safety and manage ethical issues. The holistic and reflexive nature of SBE aligns to the rich humanistic tradition nurtured within psychiatry and medicine, presenting the opportunity to expand the use of SBE to support a range of clinical skills and workforce competencies required in psychiatry.
... It has been used to model group experiences including a breakfast club and weekend sports groups, and the effect of teacher beliefs on groups of students. It has been used to model the introduction new lessons, materials or change of environment in the classroom(Nussbaumer, 2012).In health care, Cultural-Historical Activity Theory has been used to model the medical knowledge flow between organizations, interprofessional team briefings and interprofessional collaboration, and patient use of health tracking tools(Almalki, Gray, & Martin-Sanchez, 2016;Barrow, McKimm, Gasquoine, & Rowe, 2015;Eppich & Cheng, 2015;Lin, Tan, & Chang, 2008). ...
One of the most important functions of a College of Applied Arts and Technology is to provide vocational training and thus supply employers with skilled employees. Job skills include technologies and processes that change over time, and the academic program curricula at a College of Applied Arts and Technology must be updated regularly to align with current and near-future industry practices. How does a College of Applied Arts and Technology identify current worker competencies? How is the curriculum updated to incorporate these changes to reflect current and near-future industry practices? The answer to these questions at one College of Applied Arts and Technology is the focus of this study. This study describes, for four academic programs at one Ontario College of Applied Arts and Technology, the processes used by the college, corresponding accreditors and the government to identify current job skills, and the processes used to update academic programs and standards at each organization. Programs studied spanned the spectrum of Regulated, Accredited and Unregulated programs. Cyclical update processes for college curriculum, Ministry Program Standards and Accreditor competencies were examined and they map to the Plan-Do-Check-Act cycle used in Quality iii Improvement processes. Activity Theory provides a system model framework that is used to examine the college program curriculum, and the external standards including the Ministry Program Standards and Accreditor competencies for practice. The transitions systems literature reveals that in a liberal market economy, the qualification for regulated programs tightly matches the job in the labour market and the qualification for broad occupational areas loosely matches the jobs in the labour market. This study proposes a framework for understanding the relationship between vocational education curriculum and the labour market. iv
... 87,88 AT has also been used to inform complex interprofessional team debriefings, providing a way to potentially reframe observations and interactions in complex social settings, prioritise and identify additional topics for debriefing, and facilitate the identification of factors that promote or impede patient safety. 89 Like situated learning, AT brings the opportunity to investigate service-education tensions, primarily through qualitative means although quantitative methods can also be used. Further, AT can be leveraged to explore sub-tensions (or the component parts leading to tensions) within or between teaching and service through the term 'contradictions'. ...
Objectives
This paper reviews why tensions between service and education persist and highlights that this is an area of medical education research (MER) that, to date, lacks a robust body of theory‐driven research. After carrying out a review of the literature on service–education tensions in medical education and training, we turn to consider how theory can help provide new insights into service–education tensions.
Methods
We conducted a search of the literature on service–education tensions since 1998 to examine the use of theory in studies on this topic.
Results
We identified 44 out of 603 relevant papers. Their focus fell into four broad categories: time residents spent on ‘service’ and ‘education’; perceptions of the balance between service and education; considerations of how best to define service and education, and the impact of structural and systems changes on education/training. Of the papers reporting primary research, the dominant methodology was the bespoke survey. Rarely were the precise natures of tensions or how different factors interact to cause tensions examined in detail.
Discussion
Through discussion and reflection, we then agreed on the applicability of four sociocultural theories for illuminating some examples of service–education tensions. We present four sociocultural theories: Holland's figured worlds, Kemmis et al.'s practice architectures, Lave and Wenger's situated learning and Engeström's cultural‐historical activity theory (CHAT or AT). We describe each and then briefly illustrate how each theory can support new ways of thinking and potential directions for research focusing on education–service tensions.
Conclusions
The use of theory in research studies will not resolve service–education tensions. However, what theory can do is illuminate and magnify different aspects of service–education tensions, to generate new insight and knowledge that can then be used to inform future research and changes in practice.
... While activity theory has been used in considerations of team work in clinical settings [32,33,[38][39][40][41] its use in IPL is relatively novel. Activity theory has been applied to communication [42], student clinical placements [43], and team debriefings [44], but not specifically to curriculum development and implementation. Our study has used activity theory to reveal contradictions and tensions in IPL curriculum development and delivery. ...
Background:
Despite interprofessional learning (IPL) being widely recognised as important for health care professions, embedding IPL within core curriculum remains a significant challenge. The aim of this study was to identify tensions associated with implementing IPL curriculum for educators and clinical supervisors, and to examine these findings from the perspective of activity theory and the expansive learning cycle (ELC).
Methods:
We interviewed 12 faculty staff and ten health practitioners regarding IPL. Interviews were semi-structured. Following initial thematic analysis, further analysis was undertaken to characterise existing activity systems and the contradictions associated with implementing IPL. These findings were then mapped to the ELC.
Results:
Five clusters of contradictions were identified: the lack of a workable definition; when and what is best for students; the leadership hot potato; big expectations of IPL; and, resisting cultural change. When mapped to the ELC, it was apparent that although experienced as challenges, these contradictions had not yet generated sufficient tension to trigger 'break through' novel thinking, or contemplation and modelling of new solutions.
Conclusions:
The application of activity theory and the ELC offered an approach in which the most troublesome challenges might be reframed as opportunities for change. Seemingly intractable problems could be worked on to identify and address underlying fears and assumptions. If sufficient tension can be generated, an ELC could then be triggered. In reframing challenges as opportunities, the power of tensions and contradictions as potential levers for effective change might be more successfully accessed.
... We selected three simulation scholars with an established track record of publications in simulation education, representing substantive programs of simulation scholarship with different topics of focus. The scholars selected were Ryan Brydges [Self-Regulated Learning -9 papers (Brydges et al. 2009 Woods et al. 2011;Brydges and Butler 2012;Brydges et al. , 2015Ilgen and Brydges 2017)], Adam Cheng [Debriefing -12 papers (Brett-Fleegler et al. 2012;Cheng et al. 2013;Cheng et al. 2014a;Mullan et al. 2014;Cheng, Palaganas, et al. 2015;Eppich and Cheng 2015a, Kessler et al. 2015Cheng et al. 2016Cheng et al. , 2017Bajaj et al. 2018)], and Aaron Calhoun [Deception in Simulation -7 papers (Calhoun AW et al. 2013Calhoun et al. 2015aCalhoun et al. , 2015bTripathy et al. 2016;Calhoun and Gaba 2017;McBride et al. 2017)]. We purposefully selected programs of research led by two authors of this paper as this allowed for us to capture how describing patterns of METRICS scholarship expressed in their own programs of research may potentially influence their pursuit of future scholarly activities. ...
Introduction: In this paper, we explored the utility and value of the METRICS model for modeling scholarship in healthcare simulation by: (1) describing the distribution of articles in four healthcare simulation journals across the seven areas of METRICS scholarship; and (2) appraising patterns of scholarship expressed in three programs of simulation scholarship and reflecting on how these patterns potentially influence the pursuit of future scholarly activities.
Methods: Two raters reviewed abstracts of papers published between January 2015 and August 2017 in four healthcare simulation journals and coded them using METRICS. Descriptive statistics were calculated for scholarship type and distribution across journals. Twenty-eight articles from three scholars were reviewed, with patterns of scholarship within articles mapped to METRICS. Descriptive synthesis was constructed through discussion between two reviewers.
Results: A total of 432 articles from four journals were reviewed. The three most commonly published areas of scholarship were: 32.2% (139/432) evaluation, 18.8% (81/432) innovation, and 15.3% (66/432) conceptual. The METRICS model was able to represent different kinds of scholarship expressed in all of the papers reviewed and across programs of research. Reflecting on patterns of scholarship within their scholarly programs was helpful for research in planning future directions.
Conclusions: The METRICS model for scholarship can describe a wide range of patterns of simulation scholarship within individual articles, programs of research, or across journals.
... For example, Allen and his colleagues (Allen, Brown, Karanasios, & Norman, 2013;Allen, Karanasios, & Slavova, 2011) at Leeds University in the United Kingdom had used CHAT in analyzing how information behaviors (or informationseeking behaviors) were influenced and formed through interaction with context, technology, organizational adaptation, and change. Activity theory has also been used in analyzing a variety of social structures in medical care; that is, paramedic's information behaviors (Allen et al., 2013), or healthcare problems (Greig, Entwistle, & Beech, 2012) and medical education-for example, simulations in nurse training (Eppich & Cheng, 2015). ...
This program evaluation study examines an implementation of a one-to-one laptop initiative in a rural high school. Specifically, the researchers adopted a holistic view in evaluating the process and outcomes of this implementation by examining the interrelationships among the key participants using activity theory as a conceptual framework. Through using activity theory as a conceptual framework, the researchers gained a comprehensive perspective in examining the successes, challenges, and obstacles of this implementation. Therefore, not only were the individual stakeholders examined but more importantly, the interrelationships that shaped the implementation were studied to elucidate a clearer picture of the process.
... The interpretivist perspective, most common in educational theories, is represented by theories from the performing arts (Smith, Gephardt, & Nestel, 2015) and education (Husebo, O'Regan, & Nestel, 2015;Kelly & Hager, 2015). The critical theorist perspective is aligned most strongly with CulturaleHistorical Activity Theory (CHAT), a sociomaterial perspective (Eppich & Cheng, 2015). In each article, the authors describe the theory, its origins, and apply the theory to an element of simulation-based education. ...
In this article, we introduce readers to the role of theories in simulation-based education. We discuss "theory" against a background of complex ways of thinking about the world. We present our notion of theory as a framework of ideas, which illuminates simulation-based educational practice. Theories are derived from, and resonate with, educators' worldviews. We offer a foreword to five articles in Clinical Simulation in Nursing that explore specific theories applied to simulation-based education. These frameworks challenge educators' thinking and practices. We have divided the article into three parts. In Part 1, we define theories and consider concepts of worldviews and two metaphors-of theories as lenses and as liquids. In Part 2, we describe why theory is important for simulation-based education and consider the breadth of theories, referring to commonly and less commonly cited theories. In Part 3, we orientate readers to the five articles from postpositivist, interpretivist, and critical theory worldviews, specifically from theories of Cognitive Load, Reflective Cycle, Informal Learning, Stanislavski's System, and Cultural Historical Activity Theory. We conclude on an exciting note that, through the articles in this series and elsewhere, theories are increasingly being conceptualized, adapted, and applied to simulation-based health professional education. © 2015 International Nursing Association for Clinical Simulation and Learning.
... The interpretivist perspective, most common in educational theories, is represented by theories from the performing arts (Smith, Gephardt, & Nestel, 2015) and education (Husebo, O'Regan, & Nestel, 2015;Kelly & Hager, 2015). The critical theorist perspective is aligned most strongly with CulturaleHistorical Activity Theory (CHAT), a sociomaterial perspective (Eppich & Cheng, 2015). In each article, the authors describe the theory, its origins, and apply the theory to an element of simulation-based education. ...
In this article, we introduce readers to the role of theories in simulation-based education. We discuss ''theory'' against a background of complex ways of thinking about the world. We present our notion of theory as a framework of ideas, which illuminates simulation-based educational practice. Theories are derived from, and resonate with, educators' worldviews. We offer a foreword to five articles in Clinical Simulation in Nursing that explore specific theories applied to simulation-based education. These frameworks challenge educators' thinking and practices. We have divided the article into three parts. In Part 1, we define theories and consider concepts of worldviews and two metaphorsdof theories as lenses and as liquids. In Part 2, we describe why theory is important for simulation-based education and consider the breadth of theories, referring to commonly and less commonly cited theories. In Part 3, we orientate readers to the five articles from postpositivist, interpretivist, and critical theory worldviews, specifically from theories of Cognitive Load, Reflective Cycle, Informal Learning, Stanislavski's System, and Cultural Historical Activity Theory. We conclude on an exciting note that, through the articles in this series and elsewhere, theories are increasingly being conceptualized, adapted, and applied to simulation-based health professional education.
Statement:
Despite the critical importance of debriefing in simulation-based education, existing literature offers little guidance on how debriefing skills develop over time. An elaboration of the trajectory through which debriefing expertise evolves would help inform educators looking to enhance their skills. In this article, we present a new conceptual framework for the development of debriefing skills based on a modification of Dreyfus and Dreyfus' model of skill development. For each of the 3 stages of debriefing skill development-discovery, growth, and maturity, we highlight characteristics of debriefers, requisite knowledge, and key skills. We propose how faculty development experiences map to each stage of debriefing skill development. We hope the new conceptual framework will advance the art and science of debriefing by shaping future faculty development initiatives, research, and innovation in debriefing.
Research makes a critical contribution to healthcare simulation. Many simulation educators and practitioners wish to start researching but are not sure where to begin. This book has provided many approaches. In this chapter, we introduce practical strategies for individuals new to healthcare simulation research to help navigate the social dimensions of research processes. We offer ten tips range across the lifecycle of a research project: from seeking guidance at the start to publication at the end.
The importance of sociocultural context accounting for an individual's learning is widely accepted today. The idea of social learning was part of the conception of PBL and has been embedded in its instructional practice. PBL recognizes the critical role of social contexts and the reciprocal interaction between the social environment and the individual's cognition in shaping the wholeness of students’ understanding and competence for their profession. This chapter examines the theories that provide foundations for PBL practices and their effects on the learning outcomes. It will first discuss the theories that address the social aspects of learning, and then it examines the relationships between the PBL instructional format and process and the learning outcomes related to social, professional knowledge and skills. Lastly, it will discuss the research findings from the literature on the effects of PBL on social learning outcomes.
Authors Jacqui Knight MA is a Marie Curie (ITN) PhD researcher with the Cog-nition Institute and Transtechnology Research at Plymouth University. As a practicing artist and doctoral researcher, her research retrofits an understanding of photography as a manifestation of human engagement with matter in order to address photography's changing ontology in technological photographic practices. She is currently lead researcher for TAaCT a col-laborative research project between Digital Horizons at Torbay and South Devon NHS Foundation Trust and Transtechnology Research that aims to develop alternative and holistic approaches to medical care by reviewing the tools, methodologies and approaches in the teaching and training of health-care professionals. Within this role she is also advising on the development and curation of the hospital arts program. She has previously held numerous lecturing posts in Critical Theory and Fine Art subjects across various institutions including Cardiff Metropolitan University, Plymouth University and University of Falmouth. As co-founder of artist film lab Cinestar based in Cornwall, she has been dedicated in supporting creative work with analogue film through experimental workshops, screening events and education. She has exhibited and curated numerous film screening events and group exhibitions internationally and has had a solo show at Nancy Victor Gallery, London.
Obstetric Decision-Making and Simulation - edited by Kirsty MacLennan March 2019
Simulation‐based learning (SBL) is regularly integrated into the undergraduate curriculum of diverse health professions education programmes where students learn diverse clinical skills, such as patient assessment, procedural skills, and teamwork. Establishing well‐defined goals is central to the simulation instructional design process and should be done early on because it helps inform later decisions about which simulation method and modalities to use and helps inform decisions about assessment and feedback. Designing a simulation activity or curriculum also requires considering which simulation method(s) will best support the goals and objectives outlined at the beginning. This chapter presents a comparison of skills‐based and scenario‐based simulations, looking at reasons for use, common examples, and rules of participation that should be considered when designing a course or curriculum that integrates SBL. Some common applications of SBL include supporting patient safety and quality programmes, skills training and competency assessment, ameliorating clinical teaching constraints, and supporting the development of interprofessional collaborative practice.
This section starts with a list of general debriefing tips and advice about preventing and handling difficult debriefing situations that are applicable to most circumstances and will benefit simulation educators. It then addresses a series of commonly faced issues or queries that are often discussed in the simulation community. Whether or not to play back the video recording in the debriefing process is often debated, and research is still inconclusive as there are so many possible confounding factors. Similarly, insight into the use of within-scenario debriefing is provided with support from relevant references. An additional approach that can be perceived as being a supportive measure for learners new to simulation-based education followed by debriefing is the provision of a complete demonstration cycle, live or by playing back a recording of the whole process. On the other hand, a real dilemma sometimes faced by simulation educators relates to the mutual promise of confidentiality in relation to simulation session with learners and the potentially very concerning performance or behaviour of a participant. An introduction to rapid cycle deliberate practice in relation to how it affects debriefing is presented. Finally we briefly review the current debriefing assessment tools.
This Guide provides an overview of educational theory relevant to learning from experience. It considers experience gained in clinical workplaces from early medical student days through qualification to continuing professional development. Three key assumptions underpin the Guide: learning is 'situated'; it can be viewed either as an individual or a collective process; and the learning relevant to this Guide is triggered by authentic practice-based experiences. We first provide an overview of the guiding principles of experiential learning and significant historical contributions to its development as a theoretical perspective. We then discuss socio-cultural perspectives on experiential learning, highlighting their key tenets and drawing together common threads between theories. The second part of the Guide provides examples of learning from experience in practice to show how theoretical stances apply to clinical workplaces. Early experience, student clerkships and residency training are discussed in turn. We end with a summary of the current state of understanding.
The experiential learning process involves participation in key experiences and analysis of those experiences. In health care, these experiences can occur through high-fidelity simulation or in the actual clinical setting. The most important component of this process is the postexperience analysis or debriefing. During the debriefing, individuals must reflect upon the experience, identify the mental models that led to behaviors or cognitive processes, and then build or enhance new mental models to be used in future experiences. On the basis of adult learning theory, the Kolb Experiential Learning Cycle, and the Learning Outcomes Model, we structured a framework for facilitators of debriefings entitled "the 3D Model of Debriefing: Defusing, Discovering, and Deepening." It incorporates common phases prevalent in the debriefing literature, including description of and reactions to the experience, analysis of behaviors, and application or synthesis of new knowledge into clinical practice. It can be used to enhance learning after real or simulated events.
Evidence that medical error can cause harm to patients has raised the attention of the health care community towards patient safety and influenced how and what medical students learn about it. Patient safety is best taught when students are participating in clinical practice where they actually encounter patients at risk. This type of learning is referred to as workplace learning, a complex system in which various factors influence what is being learned and how. A theory that can highlight potential difficulties in this complex learning system about patient safety is activity theory. Thirty-four final year undergraduate medical students participated in four focus groups about their experiences concerning patient safety. Using activity theory as analytical framework, we performed constant comparative thematic analysis of the focus group transcripts to identify important themes. We found eight general themes relating to two activities: learning to be a doctor and delivering safe patient care. Simultaneous occurrence of these two activities can cause contradictions. Our results illustrate the complexity of learning about patient safety at the workplace. Students encounter contradictions when learning about patient safety, especially during a transitional phase of their training. These contradictions create potential learning opportunities which should be used in education about patient safety. Insight into the complexities of patient safety is essential to improve education in this important area of medicine.
Cultural Historical Activity Theory (CHAT) has its origins in Lev Vygotsky's pioneering work in the 1920s. More recently, education scholars have used CHAT to study learning behavior through the creation of activity systems analysis. Activity Systems Analysis Methods brings the CHAT framework into clear practical focus to offer a non-dualistic perspective on contemporary learning process in context. By focusing especially on methodologies, and including numerous real-life examples, the book moves beyond the theoretical realm to provide readers with expert guidance in mapping and evaluating complex learning interactions in natural environments. This first-of-its kind volume: Summarizes the theoretical development of CHAT and activity systems analysis. Explains how researchers perform activity systems analysis, and ways it benefits educational research and practice. Addresses challenges to the validity of activity systems analysis. Provides detailed examples of activity systems analysis used toward various research goals. Identifies methodological issues salient to designing and conducting CHAT-related studies in qualitative research. Refers readers to additional resources on activity systems analysis theory, methods, and issues. Education researchers, particularly in instructional technology and design, learning sciences, and educational psychology, will find Activity Systems Analysis Methods an exciting resource for adding new relevance and value to their work.
Statement:
We describe an integrated conceptual framework for a blended approach to debriefing called PEARLS [Promoting Excellence And Reflective Learning in Simulation]. We provide a rationale for scripted debriefing and introduce a PEARLS debriefing tool designed to facilitate implementation of the new framework. The PEARLS framework integrates 3 common educational strategies used during debriefing, namely, (1) learner self-assessment, (2) facilitating focused discussion, and (3) providing information in the form of directive feedback and/or teaching. The PEARLS debriefing tool incorporates scripted language to guide the debriefing, depending on the strategy chosen. The PEARLS framework and debriefing script fill a need for many health care educators learning to facilitate debriefings in simulation-based education. The PEARLS offers a structured framework adaptable for debriefing simulations with a variety in goals, including clinical decision making, improving technical skills, teamwork training, and interprofessional collaboration.
In the busy clinical environment, clinicians often struggle to turn clinical events into learning opportuni-ties. Educational methods in this setting should work within the time constraints of duty work hour restric-tions, be tailored to the relevant educational needs of adult learners, and engage interprofessional partners whenever possible. These teaching moments should ad-dress the Accreditation Council for Graduate Medical Education (ACGME) core competencies and provide the educator with bidirectional learning opportunities as well. Seizing the educational potential of clinical events can be challenging for clinician-educators. Postevent de-briefing is an underused educational mode that satis-fies all of these goals. Benefits of Debriefing Why should clinician-educators strive to include more debriefing in the clinical environment and how does postevent debriefing address the core competencies? Debriefing is a discussion of actions and thought pro-cesses after an event to promote reflective learning and improved clinical performance. When applied to Kolb's theory of experiential learning, the clinical encounter represents the "concrete experience," whereas debriefing encompasses the next 2 steps: "reflective observation," in which the educator reviews and reflects on the previous experience, and "abstract conceptualization," in which the learner identifies new concepts to apply to future practice. Debriefing after simulated clinical experiences and procedural skills is an effective educational strategy.
One vital aspect of emergency medicine management is communication after episodes of care to improve future performance through group reflection on the shared experience. This reflective activity in teams is known as debriefing, and despite supportive evidence highlighting its benefits, many practitioners experience barriers to implementing debriefing in the clinical setting.
The aim of this article is to review the current evidence supporting post-event debriefing and discuss practical approaches to implementing debriefing in the emergency department. We will address the “who, what, when, where, why and how” of debriefing and provide a practical guide for the clinician to facilitate debriefing in the clinical environment.
In the absence of theoretical or empirical agreement on how to establish and maintain engagement in instructor-led health care simulation debriefings, we organize a set of promising practices we have identified in closely related fields and our own work. We argue that certain practices create a psychologically safe context for learning, a so-called safe container. Establishing a safe container, in turn, allows learners to engage actively in simulation plus debriefings despite possible disruptions to that engagement such as unrealistic aspects of the simulation, potential threats to their professional identity, or frank discussion of mistakes. Establishing a psychologically safe context includes the practices of (1) clarifying expectations, (2) establishing a "fiction contract" with participants, (3) attending to logistic details, and (4) declaring and enacting a commitment to respecting learners and concern for their psychological safety. As instructors collaborate with learners to perform these practices, consistency between what instructors say and do may also impact learners' engagement.
The purpose of medical education is to benefit patients by improving the work of doctors. Patient centeredness is a centuries old concept in medicine, but there is still a long way to go before medical education can truly be said to be patient centered. Ensuring the centrality of the patient is a particular challenge during medical education, when students are still forming an identity as trainee doctors, and conservative attitudes towards medicine and education are common amongst medical teachers, making it hard to bring about improvements. How can teachers, policy makers, researchers and doctors bring about lasting change that will restore the patient to the heart of medical education? The authors, experienced medical educators, explore the role of the patient in medical education in terms of identity, power and location. Using innovative political, philosophical, cultural and literary critical frameworks that have previously never been applied so consistently to the field, the authors provide a fundamental reconceptualisation of medical teaching and learning, with an emphasis upon learning at the bedside and in the clinic. They offer a wealth of practical and conceptual insights into the three-way relationship between patients, students and teachers, setting out a radical and exciting approach to a medical education for the future.
Cultural-historical activity theory has evolved through three generations of research. The emerging third generation of activity theory takes two interacting activity systems as its minimal unit of analysis, inviting us to focus research efforts on the challenges and possibilities of inter-organizational learning. Activity theory and its concept of expansive learning are examined with the help of four questions: 1. Who are the subjects of learning? 2. Why do they learn? 3. What do they learn? 4. How do they learn? Five central principles of activity theory are presented, namely activity system as unit of analysis, multi-voicedness of activity, historicity of activity, contradictions as driving force of change in activity, and expansive cycles as possible form of transformation in activity. Together the four questions and five principles form a matrix which is used to present a study of expansive learning in a hospital setting in Finland. In conclusion, implications of the framework for our understanding of the increasingly important horizontal dimension of learning are discussed.
In-hospital cardiac arrest is an important public health problem. High-quality resuscitation improves survival but is difficult to achieve. Our objective is to evaluate the effectiveness of a novel, interdisciplinary, postevent quantitative debriefing program to improve survival outcomes after in-hospital pediatric chest compression events.
Single-center prospective interventional study of children who received chest compressions between December 2008 and June 2012 in the ICU.
Structured, quantitative, audiovisual, interdisciplinary debriefing of chest compression events with front-line providers.
Primary outcome was survival to hospital discharge. Secondary outcomes included survival of event (return of spontaneous circulation for ≥ 20 min) and favorable neurologic outcome. Primary resuscitation quality outcome was a composite variable, termed "excellent cardiopulmonary resuscitation," prospectively defined as a chest compression depth ≥ 38 mm, rate ≥ 100/min, ≤ 10% of chest compressions with leaning, and a chest compression fraction > 90% during a given 30-second epoch. Quantitative data were available only for patients who are 8 years old or older. There were 119 chest compression events (60 control and 59 interventional). The intervention was associated with a trend toward improved survival to hospital discharge on both univariate analysis (52% vs 33%, p = 0.054) and after controlling for confounders (adjusted odds ratio, 2.5; 95% CI, 0.91-6.8; p = 0.075), and it significantly increased survival with favorable neurologic outcome on both univariate (50% vs 29%, p = 0.036) and multivariable analyses (adjusted odds ratio, 2.75; 95% CI, 1.01-7.5; p = 0.047). Cardiopulmonary resuscitation epochs for patients who are 8 years old or older during the debriefing period were 5.6 times more likely to meet targets of excellent cardiopulmonary resuscitation (95% CI, 2.9-10.6; p < 0.01).
Implementation of an interdisciplinary, postevent quantitative debriefing program was significantly associated with improved cardiopulmonary resuscitation quality and survival with favorable neurologic outcome.
Preparing to facilitate the debriefing part of a simulation game requires as much care and attention as preparing to lead the introductory and play parts. This article provides a sort of mini-manual; explaining the nature of facilitating and then guiding the reader through the three phases of description, analysis/analogy, and application. It suggests questions a facilitator might use during each of these phases.
BACKGROUND: Improving patient safety by training teams to successfully manage emergencies is a major concern in healthcare. Most current trainings use simulation of emergency situations to practice and reflect on relevant clinical and behavioural skills. We developed TeamGAINS, a hybrid, structured debriefing tool for simulation-based team trainings in healthcare that integrates three different debriefing approaches: guided team self-correction, advocacy-inquiry and systemic-constructivist techniques.
METHODS: TeamGAINS was administered during simulation-based trainings for clinical and behavioural skills for anaesthesia staff. One of the four daily scenarios involved all trainees, whereas the remaining three scenarios each involved only two trainees with the others observing them. Training instructors were senior anaesthesiologists and psychologists. To determine debriefing quality, we used a post-test-only (debriefing quality) and a pre-post-test (psychological safety, leader inclusiveness), no-control-group design. After each debriefing all trainees completed a self-report debriefing quality scale which we developed based on the Debriefing Assessment for Simulation in Healthcare and the Observational Structured Assessment of Debriefing. Perceived psychological safety and leader inclusiveness were measured before trainees' first (premeasure) and after their last debriefing (postmeasure) at which time trainees' reactions to the overall training were measured as well.
RESULTS: Four senior anaesthetists, 29 residents and 28 nurses participated in a total of 40 debriefings resulting in 235 evaluations. Utility of debriefings was evaluated as highly positive. Pre-post comparisons revealed that psychological safety and leader inclusiveness significantly increased after the debriefings.
CONCLUSIONS: The results indicate that TeamGAINS could provide a useful debriefing tool for training anaesthesia staff on all levels of work experience. By combining state-of-the-art debriefing methods and integrating systemic-constructivist techniques, TeamGAINS has the potential to allow for a surfacing, reflecting on and changing of the dynamics of team interactions. Further research is necessary to systematically compare the effects of TeamGAINS' components on the debriefing itself and on trainees' changes in attitudes and behaviours.
In order to be relevant and impactful, our research into health care teamwork needs to better reflect the complexity inherent to this area. This study explored the complexity of collaborative practice on a distributed transplant team. We employed the theoretical lenses of activity theory to better understand the nature of collaborative complexity and its implications for current approaches to interprofessional collaboration (IPC) and interprofessional education (IPE).
Over 4 months, two trained observers conducted 162 hours of observation, 30 field interviews and 17 formal interviews with 39 members of a solid organ transplant team in a Canadian teaching hospital. Participants included consultant medical and surgical staff and postgraduate trainees, the team nurse practitioner, social worker, dietician, pharmacist, physical therapist, bedside nurses, organ donor coordinators and organ recipient coordinators. Data collection and inductive analysis for emergent themes proceeded iteratively.
Daily collaborative practice involves improvisation in the face of recurring challenges on a distributed team. This paper focuses on the theme of 'interservice' challenges, which represent instances in which the 'core' transplant team (those providing daily care for transplant patients) work to engage the expertise and resources of other services in the hospital, such as those of radiology and pathology departments. We examine a single story of the core team's collaboration with cardiology, anaesthesiology and radiology services to decide whether a patient is appropriate for transplantation and use this story to consider the team's strategies in the face of conflicting expectations and preferences among these services.
This story of collaboration in a distributed team calls into question two premises underpinning current models of IPC and IPE: the notion that stable professional roles exist, and the ideal of a unifying objective of 'caring for the patient'. We suggest important elaborations to these premises as they are used to conceptualise and teach IPC in order to better represent the intricacy of everyday collaborative work in health care.
In recent years increasing attention has been paid to issues of professionalism in surgery and the content and structure of continuing professional development for surgeons; however, little attention has been paid to interprofessional education (IPE) in surgical training. Imagining the form(s) of IPE and/or continuing interprofessional education (CIPE) programs within surgical training requires serious attention to 2 fundamental issues—the discourses of professionalism in surgery and the professional culture of surgery, as shaped and expressed within the clinical setting. We explore the possibility that concepts of professionalism within surgery may be in conflict with the tenets of interprofessionalism held by other health and medical professionals. We believe that if any rapprochement is to occur between the concept of professionalism in surgical training (and within the everyday clinical culture of surgical subspecialties groups and their professional institutions) and broader discourses of interprofessionalism circulating within health care institutions, there is a pressing need to understand and deconstruct this conflict from the point of view of surgery.
"Team" is used throughout the healthcare literature as if it had a transparent, single meaning, and in policy documents it has become a mantra. Yet, "team" is a contested and imprecise term, inviting theoretical sophistication. New forms of team working in healthcare contexts can be understood as a complex set of practices and a discourse - both performed, and written and talked about as a supplementary practice. In the context of fluid and unpredictable social conditions, teams are now theorized in terms of contradictory process as well as stable membership. Cultural-historical activity theory in particular provides a rich approach to understanding such process, in an era where the desire for stable networks - a will-to-stability - may be secondary to the need for a will-to-adaptability. A new vocabulary has emerged in theoretical accounts to describe activities of an emergent work order, in terms of a shift from stable "networking" to unstable "knotworking." However, this conceptual language can be overwrought and may alienate practitioners. Theory can be developed with practitioners themselves to avoid widening the gap between experience and the understanding and explanation of experience. Teams are not problems to be solved but activities to be expanded.
Interprofessional education, continuing interprofessional education, interprofessional collaboration, and interprofessional care are moving to the forefront of approaches with the potential to reorganize the delivery of health professions education and health care practice. This article discusses 7 key trends in the scholarship and practice of interprofessional education: conceptual clarity, quality, safety, technology, assessment of learning, faculty development, and theory. © 2009 The Alliance for Continuing Medical Education, the Society for Academic Continuing Medical Education, and the Council on CME, Association for Hospital Medical Education.
Simulation-based team training (SBTT) in healthcare is gaining acceptance. Guidelines for appropriate use of SBTT exist, but the evidence base remains limited. Insights from other academic disciplines with sophisticated models of team working may point to opportunities to build on current frameworks applied to team training in healthcare. The purpose of this consensus statement is threefold: (1) to highlight current best practices in designing SBTT in healthcare and to identify gaps in current implementation; (2) to explore validated concepts and principles from relevant academic disciplines and industries; and (3) to identify potential high-yield areas for future research and development.
We performed a selective review and critical synthesis of literature in healthcare simulation related to team learning as well as from other relevant disciplines such as psychology, business, and organizational behavior. We discuss appropriate use of SBTT and identify gaps in the literature.
Healthcare educators should apply rigorous curriculum development processes and generate learning opportunities that address the interrelated conceptual levels of team working by addressing learning needs at the level of the individual, the team, the organization, and the healthcare system. The interplay between these conceptual levels and their relative importance to team-based learning should be explored and described. Instructional design factors and contextual features that impact the effect of SBTT should be studied. Further development of validated assessment tools of team performance relevant to professional practice is a high priority and is essential to provide formative, summative, and diagnostic feedback and evaluation of SBTT. Standardized reporting of curriculum design and debriefing approaches, although difficult, would help move the field forward by allowing educators to characterize effective SBTT instruction.
Much work is needed to establish a robust and defensible evidence base for SBTT. The complexity and expense of SBTT require that specific programs or interventions are appropriately designed, implemented, and evaluated. The healthcare sector needs to understand how team performance can be optimized through appropriate training methods. The specific role of simulation in team training needs to be more clearly articulated, and the training conditions that make SBTT in healthcare effective need to be better characterized.
Progress toward understanding the links between interprofessional communication and issues of medical error has been slow. Recent research proposes that this delay may result from overlooking the complexities involved in interprofessional care. Medical education initiatives in this domain tend to simplify the complexities of team membership fluidity, rotation, and use of communication tools. A new theoretically informed research approach is required to take into account these complexities. To generate such an approach, we review two theories from the social sciences: Activity Theory and Knotworking. Using these perspectives, we propose that research into interprofessional communication and medical error can develop better understandings of (1) how and why medical errors are generated and (2) how and why gaps in team defenses occur. Such complexities will have to be investigated if students and practicing clinicians are to be adequately prepared to work safely in interprofessional teams.
To review the essential elements of crisis resource management and provide a resource for instructors by describing how to use simulation-based training to teach crisis resource management principles in pediatric acute care contexts.
A MEDLINE-based literature source. OUTLINE OF REVIEW: This review is divided into three main sections: Background, Principles of Crisis Resource Management, and Tools and Resources. The background section provides the brief history and definition of crisis resource management. The next section describes all the essential elements of crisis resource management, including leadership and followership, communication, teamwork, resource use, and situational awareness. This is followed by a review of evidence supporting the use of simulation-based crisis resource management training in health care. The last section provides the resources necessary to develop crisis resource management training using a simulation-based approach. This includes a description of how to design pediatric simulation scenarios, how to effectively debrief, and a list of potential assessment tools that instructors can use to evaluate crisis resource management performance during simulation-based training.
Crisis resource management principles form the foundation for efficient team functioning and subsequent error reduction in high-stakes environments such as acute care pediatrics. Effective instructor training is required for those programs wishing to teach these principles using simulation-based learning. Dissemination and integration of these principles into pediatric critical care practice has the potential for a tremendous impact on patient safety and outcomes.
Human errors are the most common reason for planes to crash, and of all human errors, suboptimal communication is the number 1 issue. Mounting evidence suggests the same for errors during short-term medical care. Strong verbal communication skills are key whether for establishing a shared mental model, coordinating tasks, centralizing the flow of information, or stabilizing emotions. However, in contrast to aerospace, most medical curricula rarely address communication norms during impending crises. Therefore, this article offers practical strategies borrowed from aviation and applied to critical care medicine. These crisis communication strategies include "flying by voice," the need to combat "mitigating language," the uses of "graded assertiveness" and "5-step advocacy," and the potential role of Situation, Background, Assessment, and Recommendation communication. We also outline the "step-back method," the concept of communication "below ten thousand feet," the impetus behind "closed-loop communication," and the closely related "repeat-back method." The goal is for critical care practitioners to develop a "verbal dexterity" to match their procedural dexterity and factual expertise.
As computing technology has increasingly become relevant to people's everyday lives, emphasis is being placed on ensuring Computer Assisted Learning (CAL) tools support users in ways that are meaningful to them. This requirement has highlighted the need to understand the complex and often dynamic social and cultural organisation of collaborating individuals in context. Here, the aim is to conceptualise the natural flow and evolution of work practices so as to inform the design of these systems. This paper reports on empirical findings of an investigation into the design requirements for a CAL system for supporting knowledge sharing activities in an organisation.
To develop a valid, reliable and feasible teamwork assessment measure for emergency resuscitation team performance.
Generic and profession specific team performance assessment measures are available (e.g. anaesthetics) but there are no specific measures for the assessment of emergency resuscitation team performance.
(1) An extensive review of the literature for teamwork instruments, and (2) development of a draft instrument with an expert clinical team. (3) Review by an international team of seven independent experts for face and content validity. (4) Instrument testing on 56 video-recorded hospital and simulated resuscitation events for construct, consistency, concurrent validity and reliability and (5) a final set of ratings for feasibility on fifteen simulated 'real time' events.
Following expert review, selected items were found to have a high total content validity index of 0.96. A single 'teamwork' construct was identified with an internal consistency of 0.89. Correlation between the total item score and global rating (rho 0.95; p<0.01) indicated concurrent validity. Inter-rater (k 0.55) and retest reliability (k 0.53) were 'fair', with positive feasibility ratings following 'real time' testing. The final 12 item (11 specific and 1 global rating) are rated using a five-point scale and cover three categories leadership, teamwork and task management.
In this primary study TEAM was found to be a valid and reliable instrument and should be a useful addition to clinicians' tool set for the measurement of teamwork during medical emergencies. Further evaluation of the instrument is warranted to fully determine its psychometric properties.
This article reviews and critically evaluates historical and contemporary research on simulation-based medical education (SBME). It also presents and discusses 12 features and best practices of SBME that teachers should know in order to use medical simulation technology to maximum educational benefit.
This qualitative synthesis of SBME research and scholarship was carried out in two stages. Firstly, we summarised the results of three SBME research reviews covering the years 1969-2003. Secondly, we performed a selective, critical review of SBME research and scholarship published during 2003-2009.
The historical and contemporary research synthesis is reported to inform the medical education community about 12 features and best practices of SBME: (i) feedback; (ii) deliberate practice; (iii) curriculum integration; (iv) outcome measurement; (v) simulation fidelity; (vi) skill acquisition and maintenance; (vii) mastery learning; (viii) transfer to practice; (ix) team training; (x) high-stakes testing; (xi) instructor training, and (xii) educational and professional context. Each of these is discussed in the light of available evidence. The scientific quality of contemporary SBME research is much improved compared with the historical record.
Development of and research into SBME have grown and matured over the past 40 years on substantive and methodological grounds. We believe the impact and educational utility of SBME are likely to increase in the future. More thematic programmes of research are needed. Simulation-based medical education is a complex service intervention that needs to be planned and practised with attention to organisational contexts.
First published in 1987, Learning by Expanding challenges traditional theories that consider learning a process of acquisition and reorganization of cognitive structures within the closed boundaries of specific tasks or problems. Yrjö Engeström argues that this type of learning increasingly fails to meet the challenges of complex social change and fails to create novel artifacts and ways of life. In response, he presents an innovative theory of expansive learning activity, offering a foundation for understanding and designing learning as a transformation of human activities and organizations. The second edition of this seminal text features a substantive new introduction that illustrates the development and implementation of Engeström's theory since its inception.
In a recent study of the quality of reporting experimental studies in medical education, barely half the articles examined contained an explicit statement of the conceptual framework used. Conceptual frameworks represent ways of thinking about a problem or a study, or ways of representing how complex things work. They can come from theories, models or best practices. Conceptual frameworks illuminate and magnify one's work. Different frameworks will emphasise different variables and outcomes, and their inter-relatedness. Educators and researchers constantly use conceptual frameworks to guide their work, even if they themselves are not consciously aware of the frameworks.
Three examples are provided on how conceptual frameworks can be used to cast development and research projects in medical education. The examples are accompanied by commentaries and a total of 13 key points about the nature and use of conceptual frameworks.
Ultimately, scholars are responsible for making explicit the assumptions and principles contained in the conceptual framework(s) they use in their development and research projects.
The aim of this paper is to critically review what is felt to be important about the role of debriefing in the field of simulation-based learning, how it has come about and developed over time, and the different styles or approaches that are used and how effective the process is. A recent systematic review of high fidelity simulation literature identified feedback (including debriefing) as the most important feature of simulation-based medical education. 1 Despite this, there are surprisingly few papers in the peer-reviewed literature to illustrate how to debrief, how to teach or learn to debrief, what methods of debriefing exist and how effective they are at achieving learning objectives and goals. This review is by no means a systematic review of all the literature available on debriefing, and contains information from both peer and nonpeer reviewed sources such as meeting abstracts and presentations from within the medical field and other disciplines versed in the practice of debriefing such as military, psychology, and business. It also contains many examples of what expert facilitators have learned over years of practice in the area. We feel this would be of interest to novices in the field as an introduction to debriefing, and to experts to illustrate the gaps that currently exist, which might be addressed in further research within the medical simulation community and in collaborative ventures between other disciplines experienced in the art of debriefing.
We report on our experience with an approach to debriefing that emphasizes disclosing instructors' judgments and eliciting trainees' assumptions about the situation and their reasons for acting as they did. To highlight the importance of instructors disclosing their judgment skillfully, we call the approach "debriefing with good judgment." The approach draws on theory and empirical findings from a 35-year research program in the behavioral sciences on how to improve professional effectiveness through "reflective practice." This approach specifies a rigorous self-reflection process that helps trainees recognize and resolve pressing clinical and behavioral dilemmas raised by the simulation and the judgment of the instructor. The "debriefing with good judgment" approach is comprised of three elements. The first element is a conceptual model drawn from cognitive science. It stipulates that the trainees' "frames"--comprised of such things as knowledge, assumptions, and feelings--drive their actions. The actions, in turn, produce clinical results in a scenario. By uncovering the trainee's internal frame, the instructor can help the learner reframe internal assumptions and feelings and take action to achieve better results in the future. The second element is a stance of genuine curiosity about the trainee's frames. Presuming that the trainee's actions are an inevitable result of their frames, the instructor's job is that of a "cognitive detective" who tries to discover, through inquiry, what those frames are. The instructor establishes a "stance of curiosity" in which the trainees' mistakes are puzzles to be solved rather than simply erroneous. Finally, the approach includes a conversational technique designed to bring the judgment of the instructor and the frames of the trainee to light. The technique pairs advocacy and inquiry. Advocacy is a type of speech that includes an objective observation about and subjective judgment of the trainees' actions. Inquiry is a genuinely curious question that attempts to illuminate the trainee's frame in relation to the action described in the instructor's advocacy. We find that the approach helps instructors manage the apparent tension between sharing critical, evaluative judgments while maintaining a trusting relationship with trainees.
The authors present a four-step model of debriefing as formative assessment that blends evidence and theory from education research, the social and cognitive sciences, experience drawn from conducting over 3,000 debriefings, and teaching debriefing to approximately 1,000 clinicians worldwide. The steps are to: 1) note salient performance gaps related to predetermined objectives, 2) provide feedback describing the gap, 3) investigate the basis for the gap by exploring the frames and emotions contributing to the current performance level, and 4) help close the performance gap through discussion or targeted instruction about principles and skills relevant to performance. The authors propose that the model, designed for postsimulation debriefings, can also be applied to bedside teaching in the emergency department (ED) and other clinical settings.
Cultural-historical activity theory is a new framework aimed at transcending the dichotomies of micro- and macro-, mental and material, observation and intervention in analysis and redesign of work. The approach distinguishes between short-lived goal-directed actions and durable, object-oriented activity systems. A historically evolving collective activity system, seen in its network relations to other activity systems, is taken as the prime unit of analysis against which scripted strings of goal-directed actions and automatic operations are interpreted. Activity systems are driven by communal motives that are often difficult to articulate for individual participants. Activity systems are in constant movement and internally contradictory. Their systemic contradictions, manifested in disturbances and mundane innovations, offer possibilities for expansive developmental transformations. Such transformations proceed through stepwise cycles of expansive learning which begin with actions of questioning the existing standard practice, then proceed to actions of analyzing its contradictions and modelling a vision for its zone of proximal development, then to actions of examining and implementing the new model in practice. New forms of work organization increasingly require negotiated 'knotworking' across boundaries. Correspondingly, expansive learning increasingly involves horizontal widening of collective expertise by means of debating, negotiating and hybridizing different perspectives and conceptualizations. Findings from a longitudinal intervention study of children's medical care illuminate the theoretical arguments.
Work-based learning occupies a central role in the training and ongoing development of the medical workforce. With this arises the need to understand the processes involved, particularly those relating to informal learning. Approaches to informal learning in postgraduate medical education have tended to consider the mind as an independent processor of information.
In this paper, such cognitive approaches are critiqued and an alternative socio-cultural view on informal learning described. Recent and imminent changes in postgraduate medical education are identified, namely the reduction in patient experience, the fragmentation of teaching, and the development of competency frameworks and structured curricula. It is argued that although the latter may be useful in the construction of formal learning programmes, they will do little to enhance the progression of the individual from newcomer to old-timer or the cultural assimilation of the learner into a profession.
Strategies for enhancing informal learning in the workplace are recommended in which increased attention is paid to the development of the medical apprentice within a community of social practice. These include the establishment of strong goals, the use of improvised learning practices, attention to levels of individual engagement and workplace affordances, immersion in professional discourse and behaviours, support in relation to the development of a professional identity and the provision of opportunities to transform social practice.
There is a mismatch between the broad range of learning theories offered in the wider education literature and a relatively narrow range of theories privileged in the medical education literature. The latter are usually described under the heading of 'adult learning theory'.
This paper critically addresses the limitations of the current dominant learning theories informing medical education. An argument is made that such theories, which address how an individual learns, fail to explain how learning occurs in dynamic, complex and unstable systems such as fluid clinical teams.
Models of learning that take into account distributed knowing, learning through time as well as space, and the complexity of a learning environment including relationships between persons and artefacts, are more powerful in explaining and predicting how learning occurs in clinical teams. Learning theories may be privileged for ideological reasons, such as medicine's concern with autonomy.
Where an increasing amount of medical education occurs in workplace contexts, sociocultural learning theories offer a best-fit exploration and explanation of such learning. We need to continue to develop testable models of learning that inform safe work practice. One type of learning theory will not inform all practice contexts and we need to think about a range of fit-for-purpose theories that are testable in practice. Exciting current developments include dynamicist models of learning drawing on complexity theory.
Resuscitation of critically ill patients requires medical knowledge, clinical skills, and nonmedical skills, or crisis resource management (CRM) skills. There is currently no gold standard for evaluation of CRM performance. The primary objective was to examine the use of high-fidelity simulation as a medium to evaluate CRM performance. Since no gold standard for measuring performance exists, the secondary objective was the validation of a measuring instrument for CRM performance-the Ottawa Crisis Resource Management Global Rating Scale (or Ottawa GRS).
First- and third-year residents participated in two simulator scenarios, recreating emergencies seen in acute care settings. Three raters then evaluated resident performance using edited video recordings of simulator performance.
A Canadian university tertiary hospital.
: The Ottawa GRS was used, which provides a 7-point Likert scale for performance in five categories of CRM and an overall performance score.
Construct validity was measured on the basis of content validity, response process, internal structure, and response to other variables. One variable measured in this study was the level of training. A t-test analysis of Ottawa GRS scores was conducted to examine response to the variable of level of training. Intraclass correlation coefficient scores were used to measure interrater reliability for both scenarios. Thirty-two first-year and 28 third-year residents participated in the study. Third-year residents produced higher mean scores for overall CRM performance than first-year residents (p < .0001) and in all individual categories within the Ottawa GRS (p = .0019 to p < .0001). This difference was noted for both scenarios and for each individual rater (p = .0061 to p < .0001). No statistically significant difference in resident scores was observed between scenarios. Intraclass correlation coefficient scores of .59 and .61 were obtained for scenarios 1 and 2, respectively.
Data obtained using the Ottawa GRS in measuring CRM performance during high-fidelity simulation scenarios support evidence of construct validity. Data also indicate the presence of acceptable interrater reliability when using the Ottawa GRS.
Simulation offers an important context for clinical education, providing a structured, safe and supportive environment bridging the classroom and the clinic. Two trends in the simulation community appear to be developing uncritically and without adequate evaluation. First, there is a fascination with seductive high-fidelity simulation realized through sophisticated technology. Second, simulation has increasingly appropriated learning in the psychological domain, such as communication skills, under the rationale of 'integration'. Developments in simulation activities have largely been made in a theoretical vacuum and where theory is invoked it is learning theory rather than theory of simulation. This paper introduces theories of simulation from cultural studies as a critical balance to the claims of the simulation community. Work-based and simulation-based learning could engage in a new dialogue for an effective clinical education.
This article reports on an evaluation methodology development study for K-12 school and university partnerships. The method is based on Engeström's (1987). Learning by expanding: An activity-theoretical approach to developmental research. Helsinki: Orienta-Konsultit Oy activity systems analysis that allows researchers to examine qualitative datasets of complex human interactions. This study was designed for participants to evaluate partnership relations and activities. We investigated how the use of activity systems analysis in K-12 school and university partnership evaluation meetings affected participant communication processes. In this study, during a 1-day retreat K-12 school staff and university staff used a modified activity systems model to identify persisting institutional tensions in their program that often trigger miscommunications and strain their relations. During the discussion sessions, study participants collaboratively examined their partnership relations and identified strategies for overcoming difficulties. Additionally, in subsequent monthly partnership meetings during the school year, participants examined findings from the evaluation to design and implement improvement strategies. The results from this methodology development and implementation study provided researchers and partnership participants a new means to (a) evaluate partnership activities, (b) identify institutional barriers, (c) plan future activities, and (d) listen to and incorporate the ideas of less vocal staff members into the planning of future activities.
The reflective practitioner
- D Sch€ On
Sch€ on, D. (1983). The reflective practitioner. New York: Basic Books.