REVIEW URRENT C OPINION
Simulation and psychology: creating, recognizing and using learning opportunities Peter Dieckmann a and Ralf Krage b
Purpose of review Psychology is relevant for improving the use of simulation in anesthesiology, as it allows us to describe, explain and optimize the interactions of learners and instructors as well as the design of simulation scenarios and debriefings. Much psychological expertise is not used for simulation in healthcare. This article aims to help bridging the gap between professions. Recent findings The evidence is building that simulation is effective for learning. Recent psychological work improves the understanding of why this is the case – or why not. Publications range from the elements to be simulated, to optimizing the presentation of scenarios and debriefings to an organizational overview of how simulation can contribute to patient safety, healthcare worker well-beings and quality of care. The psychological analysis helps in capturing the salient characteristics of the tasks to be simulated and in implementing them in a relevant learning setting. Summary Using psychology in simulation allows us to create, recognize and use learning opportunities. The motivations of those involved can be taken into account and the simulation activity can be channeled into a goal-oriented direction. Video abstract available See the Video Supplementary Digital Content 1 (http://links.lww.com/COAN/A26). Keywords debriefing, psychology, safety, simulation
INTRODUCTION Simulation is increasingly used for education, training, research and assessment [1–4]. The evidence is building that simulation-based learning is effective for improving clinical behaviors and patient outcome [5–7,8 ]. The focus on outcome studies is debated [9 ] and more studies are needed that investigate under which conditions simulation does work and for which purposes [2,10,11]. The term simulation has many different meanings: modalities, settings, target groups and many more aspects vary [12]. We focus on manikin-based, scenario-oriented simulations including a debriefing used to improve patient safety and quality of care. Three major perspectives can describe connections between psychology and simulation: psychology of simulation, psychology within simulation and psychological contributions to research methods. Psychology of simulation describes, explains and predicts experiences and actions of participants &&
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and instructors in the simulation situation [10,13,14]. Thus, psychology can contribute to adapting simulation to the needs of the various stakeholders involved, for example the need for psychological safety of the participants; the wishes of their leader, who ordered and paid for the training; or the personal motivations of the simulation instructors. Psychology within simulation provides psychological expertise to build simulation-based
a
Danish Institute for Medical Simulation, Capital Region of Denmark, Herlev Hospital, Denmark and bVU University Medical Center, Department of Anesthesiology, ADAM Simulation Center, Amsterdam, The Netherlands Correspondence to Dr Peter Dieckmann, Capital Region of Denmark, Danish Institute for Medical Simulation (DIMS), Herlev Hospital, Herlev Ringvej 75, 2730 Herlev, Denmark. Tel: +0045 3868 2543; e-mail: [email protected] Curr Opin Anesthesiol 2013, 26:714–720 DOI:10.1097/ACO.0000000000000018 Volume 26 Number 6 December 2013
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KEY POINTS Psychology of simulation describes and explains actions and experiences of learners and instructors in simulation; psychology within simulation can be used to design relevant scenarios and debriefings. Simulation success depends on capturing the salient characteristics of the task to be simulated and the relevance of scenarios and debriefings for their goals – simulation realism is therefore a means, not an end. Not all what simulation instructors and participants experience and do can be explained with the processes within the simulation setting – personal and unconscious elements have an influence as well. Focusing on ‘everyday’ problems in healthcare instead of or in addition to rare crisis situations will help in making progress in patient safety, if the implications from such scenarios are taken as relevant expressions of systematic work processes. Known psychological characteristics of human perception, emotional and cognitive processes and actions can guide the search for and the implementation of relevant scenarios.
education on, for example, human-factors issues to optimize teamwork [15–19]. Psychology can also offer methodological input for designing and conducting research [10,20]. For example, the collaboration of psychologists and anesthesiologists resulted in a widely used taxonomy of nontechnical skills relevant for training and clinical settings [21,22].
Structure of article and theoretical considerations For this review, typical activities of simulation instructors guided our search: running scenarios and debriefings and designing scenarios and courses. With simulation instructor, we refer to the ‘teachers’ in simulation, who use a range of techniques (e.g. facilitation) to help their participants to learn. The basic psychological framework of our psychological considerations is the Field Theory by Kurt Lewin [13,23,24]. The idea is that to understand human behavior, one needs to consider the person in the situation as the object of analysis. Focusing on one part only, the person or the situation will not produce relevant insights because both are linked. The value of an action or perception, for example, depends on the dynamic development of the situation. The first intubation attempt would usually be seen as positive, whereas the fourth might be the subject of debate. Criticizing a course
participant to enjoy a feeling of superiority would be seen in most circumstances as less professional instructor behavior than criticizing with the intention to help the participant learn. The ‘silent’ participant might be experienced very different by instructors, depending on in which part of the world they meet each other [25]. Whereas in the Western world the silent participant might be seen as a challenge by the instructor, he or she might just fulfill the expectation in many Eastern countries.
On simulation scenarios A primary source of concern in running scenarios is their ‘realism’ [26,27]. We argue that realism is only a means to achieve the goal of creating learning opportunities for participants, but not a goal in itself [28]. There were early and ongoing considerations [29–31,27] and empirical findings [32,33] that support our assumption. We distinguish the physical basis of simulation, which can be measured in length, weight and duration, the semantical aspects that describe the construction of meaning enabled by the simulation and the phenomenal aspects that describe how the simulation situation is experienced [28]. Although the physical basis of simulation is altered as compared with the clinical setting (the patient is from plastic and not flesh), the semantical meaning often can be preserved (participants recognize that the scenario is meant to depict anaphylaxis) and the experience can be comparable (despite ‘extra’ elements, from being observed during simulation) [34]. Depending on the salient characteristics of the task to be simulated, different aspects of realism are needed to be adapted for the training situation. The training of needle insertion might require high physical realism to allow learners to get the resistant patterns into their fingertips. The training of communication skills could work well with abstract exercises that preserve meaning and experiences. A study looking at connections between realism and learning focusing on IV needle placement discussed the integration of simulators of different fidelity for the focus of different aspects of the task [35]. The study combined, however, characteristics of the simulator itself (e.g. haptic feedback) and characteristics of the surrounding tasks (e.g. involving the patient in role play or not). A study from Tanzania shows that there can be great effects with ‘low fidelity simulator’ – a plastic doll filled with water [8 ]. The manikin allows for capturing the salient characteristics of helping newborns in the golden minute after birth.
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By integrating the simulator into a curriculum and by combining it with faculty development and culture-sensitive training material, the project succeeded in contributing to the reduction of neonatal deaths within 24 h after birth from 13.4 in 1000 to 7.1 in 1000. The project aimed to address a WHO Millenium Goal, which was based on local needs analysis [36] and thus can serve as a model in many regards. Some scenario-relevant issues beyond the realism debate are not yet to be found in publications, so we relate to our experience from instructor courses. Not everything what instructors do is completely aimed at helping participants to learn. Some elements of instructor motivation could be described as ‘joy of controlling’ the fate of the participants, others as a feeling of success, when participants recognize the scenario and accept it as relevant. Thus, the motivation for any design decision and adaptation of running scenarios is important. Is it to create and use learning opportunities for the participants or is the (maybe even unconscious) motivation to make the instructor feel better? Is the realism maximized because it is relevant for the learning goals, or to avoid being attacked by the participants for a ‘bad scenario’? In other words: does the scenario serve the participants or the instructor?
On debriefings Debriefing after scenarios is seen as an important part of simulation practice [37] and is considered the ‘heart and soul’ [38] of simulation-based training. Raemer et al. [11] reviewed the current state of research on debriefing and provide a framework for further studies. A meta-analysis summarizing results from 2136 participants estimated the average positive learning effect of adding debriefings to trainings to 25%. In those cases in which the debriefing method and the training content were aligned with the learning needs of the participants (e.g. facilitated discussion in a team, focusing on
teamwork issues), positive effects were estimated to reaching 38%. Adding a visual aid, like video playback, however, was not seen as adding extra effects [39]. Tannenbaum and Cerasoli [39] speculate about artifacts in regard of the video use because debriefings that are researched might be so good anyway that adding video might not yield any extra benefit. Despite the negative findings, we recommend using video from our own experience as it offers such great potentials. A study found that it might not even be necessary to have an instructor guide the debriefing, if the group manages to stay on track while analyzing their performance [40]. In a post-test scenario, the two study groups showed comparable benefits of the debriefing, regardless of whether the debriefer led the debriefing or the group selforganized this process. When looking into the why debriefings work, it is important to see the integration of the debriefing into the larger context of the simulation setting [13]. The scenario, how it was introduced, or in which atmosphere the course was started, has a strong influence on how a debriefing will run. Kolbe et al. [41] describe a way to create a reflective setting during debriefings by combining ‘classic’ debriefing techniques with techniques from systemic therapy. They combine guided self-correction, the advocacy and inquiry technique [42,43], and circular questions (see Fig. 1 for an example). The approach redefines the combination of listening, talking and reflecting during a debriefing. As during scenarios, during debriefings also, instructors might not always only have the learning of the participants in mind. One classical example can be explained with the ‘please me’ driver known in transactional analysis [44]. The instructor in this case might strive to be pleased by the participants (Fig. 2). As a consequence, some difficult discussions might be avoided or goaloriented feedback might be withheld. A study found substantial differences in the official ratings of students in problem-based learning environments as compared with ‘unofficial’ ratings collected
Circular questions aim to describe an interaction of two or more persons as a further person would see it. For example, the debriefer might ask the anesthesiologist: When you came into the room and asked the nurse about the allergies of the patient – how do you think the patient perceived the answer of the nurse? Circular questions force the person answering to mentally change perspectives and see the world with different eyes. They can thus provide some unique insights.
FIGURE 1. Examples of circular questions. Adapted with permission from [44]. 716
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Please me!
Please like me!
Please - may I join?
FIGURE 2. Instructors (dotted) might be inhibited to make clear learning points by their wish to be pleased by the participants (striped).
retrospectively. The quantitative ratings correlated only to a medium level or lower with each other and the qualitative comments were almost in the opposite direction (vague and positive in the official version and more specific and more negative in the unofficial rating) [45]. Growing into a professional role as (simulation) facilitator might thus mean also to become aware of hidden motivations and finding a way to deal with them. Several attempts are made to assess the quality of debriefings. The first known to us was the Debriefing Assessment in Healthcare [46]. A new tool stems from the surgical context, the Objective Structured Assessment of Debriefing [47]. Both approaches are based on observing debriefings and assessing instructor behavior with rating scales. Although we do see a lot of benefits in assessing debriefings, we suspect that some issues discussed above – concerning the intention of an action – might not be captured with observational tools alone. There seems to be a ‘feeling’ that has some value to it, but that might be difficult to capture in figures and that nevertheless has value to be considered [48].
Designing courses and scenarios In this section, we reflect upon content of simulation scenarios and methodological issues when implementing them. Content aspects A common approach is to look at typical challenges and to replicate those in the simulator [49]. Scenarios could be selected based on their likelihood of occurrence, likelihood of an impact of training, the scope of the impact for the patient, the relatives and the healthcare professionals. We believe that optimizing ‘everyday’ challenges
such as anaphylaxis or perioperative bleeding may be superior to training rare events (e.g. malignant hyperthermia), even though they might not look and feel spectacular. Based on their frequent occurrence and on our assumption that optimizing everyday challenges will have positive impacts on crisis situations, we assume a large benefit of focusing on the whole range of possible scenarios. The debate about whether and why the simulated patient should ‘die’ during simulation took up speed again in conjunction with a discussion of scenarios that are overall psychologically challenging for participants [50–54]. We believe this debate is important, as it would open a potential new realm to use simulation in all those aspects that cannot be managed medically successful. In our view, it is beneficial to explore the role of simulation further to prepare healthcare professionals for their ‘dark moments’ [55–58]. The ‘Francis Report’ investigated challenges in a trust in the UK [59] that are also relevant for simulation-based training. Many of the challenges found were not directly related to the medical treatment in itself, but to the care provided to patients, before, during and after the actual treatment, addressing, for example, hygiene, nutrition and dignity. The key finding applicable to simulation is that scenarios might need to include those issues around the pure care, as they might be essential parts of the tasks to be done and can make or break the success. This would also imply to consciously design scenarios that include the handover of the patient between participants; the beginning and end of simulated cases might need to be moved, so that an overlap between cases is implemented. Psychological aspects of the needs analysis could help in revising the ‘boarders’ of scenarios to improve the inclusion of salient characteristics of the tasks simulated. Two recent books can direct the search for a psychological view on the challenges in healthcare. Gigerenzer and Gray describe and explain how healthcare professionals (mis)interpret much of the diagnostic information they handle every day [60]. Nobel prize winner Daniel Kahnemann takes a different angle on similar challenges and investigates how shortcuts in perceiving and thinking that make the human cognitive system so efficient can pose challenges in other instances [61]. These books and the publications to which they refer can serve as an invaluable source of inspiration and concrete guidance to design scenarios. One might hope that such a scenario could almost work like a vaccine: when participants experience the impact of cognitive biases and discuss the underlying mechanisms in the debriefing, they might be able to deal with
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them more effectively in clinical care – at least for some time, while the vaccine is fresh. Finally, we highly recommend two recent books by Nance [62 ,63 ]. A key message of the books we emphasize is to make patient safety and quality of care the core of any healthcare endeavor. One way of doing this is to rethink the professional distance between healthcare professionals and patients, allowing the negative impact that safety challenges have for patients to get much closer to the healthcare professionals than it in current practice. Reducing this distance for sure has advantages and disadvantages and practical implications could be investigated to some extent in simulation. &&
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Methodological aspects A recent meta-analysis was investigated, using part task training strategies [64 ]. The authors analyzed 37 studies investigating transfer of learning from a range of domains. Learners benefitted from part task training in those situations, in which the trained tasks needed to be performed in sequence in the actual work environment. In those instances, however, in which the actual task had elements that needed to be handled in parallel, it led to lower transfer of learning when these elements were separated during training. The learners did not learn the vital element of time sharing. In our view, this finding has an implication for the design of scenarios and courses in healthcare and implies that technical–medical issues should not be separated from nontechnical issues. A strategy to help learners balance both areas is called variablepriority-training, in which all the elements of the real-world complexity are preserved in training, but a clear focus is placed on a subset of those [64 ]. For example, it might be possible to run medically oriented scenarios of difficult airway management including issues of team interactions. Other scenarios might focus on team aspects, using difficult airway situations just as an example. One underlying assumption of current simulation practice is that people learn from errors. However, this seems to be more difficult than one might think. Loh et al. [65 ] discuss the impact of cognitive ability and personality type on the learning from errors. Higher clinical ability, the openness for making new experiences and less concern about doing everything correctly (conscientiousness) were related to benefits from error management trainings. Such trainings focus on encouraging exploring new options and describe the learning from errors as positive. It can be contrasted with error avoidance trainings that help learners to do the tasks correctly &
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in the first place. An underlying theoretical assumption is that the focus on errors, whether in terms of management or avoidance, takes cognitive and emotional resources in itself. This way those learners would benefit, who either simply have more resources because of their higher abilities and those learners whose traits are in line with the focus on errors. Besides the focus on errors, the encouragement to explore a task was related to better transfer of learning. An interview study conducted with former participants of courses for advanced life support can be interpreted in a similar way [66 ], as the courses can be seen as examples of error avoidance type of training. Participants described the experience as helpful in the regard of getting firm guidance on practice by ‘black and white’ information about what is correct or incorrect in their treatment. The drill-type aspects of the training were reported to have strengths in groups of people who all worked according to the same principles and under standardized circumstances (e.g. all equipment needed actually available). Participants also reported challenges when applying the competences gained in the course in more complex and ill-structured real-world situations. The conclusion of the study was that these trainings have strengths in effectively learning how to treat certain types of clinical situations but had challenges in the application of those treatment algorithms in the ‘real’ world. &&
CONCLUSION We discussed selected connections between psychology and simulation in anesthesiology. Many psychological theories, frameworks and methods are relevant for optimizing the use of simulation – both, to optimize the psychology of simulation and using psychology within simulation to address known patient safety issues in a more effective way. It takes time and energy and much mutual learning to build fruitful co-operations between psychologists and anesthesiologists, but from our experience, the effort is well spent.
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Acknowledgements We thank our colleague Anne Lippert, MD, from the Danish Institute for Medical Simulation (DIMS) for valuable input for this paper. Conflicts of interest DIMS has a collaboration agreement with Laerdal, a manufacturer of simulators. DIMS receives research funding from the Laerdal foundation. DIMS is part of
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the EuSim group, providing faculty development programmes. The work on this manuscript was funded by institutional funds. Ralf Krage has no conflicts of interest.
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Technology, education, training and information systems 56. Jones JH, Treiber LA. When nurses become the ‘second’ victim. Nurs Forum 2012; 47:286–291. 57. McCay L, Wu AW. Medical error: the second victim. Br J Hosp Med (Lond) 2012; 73:C146–C148. 58. Manser T. Managing the aftermath of critical incidents: meeting the needs of health-care providers and patients. Best Pract Res Clin Anaesthesiol 2011; 25:169–179. 59. Francis R. Independent inquiry into care provided by mid Staffordshire NHS Foundation Trust January 2005–March 2009. The Stationery Office; 2010. 60. Gigerenzer G, Gray JAM. Better doctors, better patients, better decisions. MIT Press; 2011. 61. Kahneman D. Thinking fast slow. Farrar, Straus, and Giroux; 2012. 62. Nance JJ. Why hospitals should fly. Debolsillo; 2008. &&
A mind-changing experience to read this book and its successor ‘Charting the course’. If you work in the healthcare system, if you ever go there, if any of your relatives do – read this book.
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63. Nance JJ, Bartholomew K. Charting the course. Debolsillo; 2012. &&
A mind-changing experience to read this book. If you work in the healthcare system, if you ever go there, if any of your relatives do – read this book. 64. Wickens CD, Hutchins S, Carolan T, Cumming J. Effectiveness of part-task & training and increasing-difficulty training strategies: a meta-analysis approach. Hum Fac 2013; 55:461–470. Great guidance around fine tuning the sequences in your training sessions. 65. Loh V, Andrews S, Hesketh B, Griffin B. The moderating effect of individual & differences in error-management training: who learns from mistakes? Hum Fac 2013; 55:435–448. Makes the case that not one side fits all in terms of feedback. 66. Rasmussen MB, Dieckmann P, Barry Issenberg S, et al. Long-term intended && and unintended experiences after advanced life support training. Resuscitation 2012; 84:373–377. This review discusses potential negative long-term effects of using simulation.
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Simulation and psychology: creating, recognizing and using learning opportunities Peter Dieckmann a and Ralf Krage b
Purpose of review Psychology is relevant for improving the use of simulation in anesthesiology, as it allows us to describe, explain and optimize the interactions of learners and instructors as well as the design of simulation scenarios and debriefings. Much psychological expertise is not used for simulation in healthcare. This article aims to help bridging the gap between professions. Recent findings The evidence is building that simulation is effective for learning. Recent psychological work improves the understanding of why this is the case – or why not. Publications range from the elements to be simulated, to optimizing the presentation of scenarios and debriefings to an organizational overview of how simulation can contribute to patient safety, healthcare worker well-beings and quality of care. The psychological analysis helps in capturing the salient characteristics of the tasks to be simulated and in implementing them in a relevant learning setting. Summary Using psychology in simulation allows us to create, recognize and use learning opportunities. The motivations of those involved can be taken into account and the simulation activity can be channeled into a goal-oriented direction. Video abstract available See the Video Supplementary Digital Content 1 (http://links.lww.com/COAN/A26). Keywords debriefing, psychology, safety, simulation
INTRODUCTION Simulation is increasingly used for education, training, research and assessment [1–4]. The evidence is building that simulation-based learning is effective for improving clinical behaviors and patient outcome [5–7,8 ]. The focus on outcome studies is debated [9 ] and more studies are needed that investigate under which conditions simulation does work and for which purposes [2,10,11]. The term simulation has many different meanings: modalities, settings, target groups and many more aspects vary [12]. We focus on manikin-based, scenario-oriented simulations including a debriefing used to improve patient safety and quality of care. Three major perspectives can describe connections between psychology and simulation: psychology of simulation, psychology within simulation and psychological contributions to research methods. Psychology of simulation describes, explains and predicts experiences and actions of participants &&
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and instructors in the simulation situation [10,13,14]. Thus, psychology can contribute to adapting simulation to the needs of the various stakeholders involved, for example the need for psychological safety of the participants; the wishes of their leader, who ordered and paid for the training; or the personal motivations of the simulation instructors. Psychology within simulation provides psychological expertise to build simulation-based
a
Danish Institute for Medical Simulation, Capital Region of Denmark, Herlev Hospital, Denmark and bVU University Medical Center, Department of Anesthesiology, ADAM Simulation Center, Amsterdam, The Netherlands Correspondence to Dr Peter Dieckmann, Capital Region of Denmark, Danish Institute for Medical Simulation (DIMS), Herlev Hospital, Herlev Ringvej 75, 2730 Herlev, Denmark. Tel: +0045 3868 2543; e-mail: [email protected] Curr Opin Anesthesiol 2013, 26:714–720 DOI:10.1097/ACO.0000000000000018 Volume 26 Number 6 December 2013
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KEY POINTS Psychology of simulation describes and explains actions and experiences of learners and instructors in simulation; psychology within simulation can be used to design relevant scenarios and debriefings. Simulation success depends on capturing the salient characteristics of the task to be simulated and the relevance of scenarios and debriefings for their goals – simulation realism is therefore a means, not an end. Not all what simulation instructors and participants experience and do can be explained with the processes within the simulation setting – personal and unconscious elements have an influence as well. Focusing on ‘everyday’ problems in healthcare instead of or in addition to rare crisis situations will help in making progress in patient safety, if the implications from such scenarios are taken as relevant expressions of systematic work processes. Known psychological characteristics of human perception, emotional and cognitive processes and actions can guide the search for and the implementation of relevant scenarios.
education on, for example, human-factors issues to optimize teamwork [15–19]. Psychology can also offer methodological input for designing and conducting research [10,20]. For example, the collaboration of psychologists and anesthesiologists resulted in a widely used taxonomy of nontechnical skills relevant for training and clinical settings [21,22].
Structure of article and theoretical considerations For this review, typical activities of simulation instructors guided our search: running scenarios and debriefings and designing scenarios and courses. With simulation instructor, we refer to the ‘teachers’ in simulation, who use a range of techniques (e.g. facilitation) to help their participants to learn. The basic psychological framework of our psychological considerations is the Field Theory by Kurt Lewin [13,23,24]. The idea is that to understand human behavior, one needs to consider the person in the situation as the object of analysis. Focusing on one part only, the person or the situation will not produce relevant insights because both are linked. The value of an action or perception, for example, depends on the dynamic development of the situation. The first intubation attempt would usually be seen as positive, whereas the fourth might be the subject of debate. Criticizing a course
participant to enjoy a feeling of superiority would be seen in most circumstances as less professional instructor behavior than criticizing with the intention to help the participant learn. The ‘silent’ participant might be experienced very different by instructors, depending on in which part of the world they meet each other [25]. Whereas in the Western world the silent participant might be seen as a challenge by the instructor, he or she might just fulfill the expectation in many Eastern countries.
On simulation scenarios A primary source of concern in running scenarios is their ‘realism’ [26,27]. We argue that realism is only a means to achieve the goal of creating learning opportunities for participants, but not a goal in itself [28]. There were early and ongoing considerations [29–31,27] and empirical findings [32,33] that support our assumption. We distinguish the physical basis of simulation, which can be measured in length, weight and duration, the semantical aspects that describe the construction of meaning enabled by the simulation and the phenomenal aspects that describe how the simulation situation is experienced [28]. Although the physical basis of simulation is altered as compared with the clinical setting (the patient is from plastic and not flesh), the semantical meaning often can be preserved (participants recognize that the scenario is meant to depict anaphylaxis) and the experience can be comparable (despite ‘extra’ elements, from being observed during simulation) [34]. Depending on the salient characteristics of the task to be simulated, different aspects of realism are needed to be adapted for the training situation. The training of needle insertion might require high physical realism to allow learners to get the resistant patterns into their fingertips. The training of communication skills could work well with abstract exercises that preserve meaning and experiences. A study looking at connections between realism and learning focusing on IV needle placement discussed the integration of simulators of different fidelity for the focus of different aspects of the task [35]. The study combined, however, characteristics of the simulator itself (e.g. haptic feedback) and characteristics of the surrounding tasks (e.g. involving the patient in role play or not). A study from Tanzania shows that there can be great effects with ‘low fidelity simulator’ – a plastic doll filled with water [8 ]. The manikin allows for capturing the salient characteristics of helping newborns in the golden minute after birth.
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By integrating the simulator into a curriculum and by combining it with faculty development and culture-sensitive training material, the project succeeded in contributing to the reduction of neonatal deaths within 24 h after birth from 13.4 in 1000 to 7.1 in 1000. The project aimed to address a WHO Millenium Goal, which was based on local needs analysis [36] and thus can serve as a model in many regards. Some scenario-relevant issues beyond the realism debate are not yet to be found in publications, so we relate to our experience from instructor courses. Not everything what instructors do is completely aimed at helping participants to learn. Some elements of instructor motivation could be described as ‘joy of controlling’ the fate of the participants, others as a feeling of success, when participants recognize the scenario and accept it as relevant. Thus, the motivation for any design decision and adaptation of running scenarios is important. Is it to create and use learning opportunities for the participants or is the (maybe even unconscious) motivation to make the instructor feel better? Is the realism maximized because it is relevant for the learning goals, or to avoid being attacked by the participants for a ‘bad scenario’? In other words: does the scenario serve the participants or the instructor?
On debriefings Debriefing after scenarios is seen as an important part of simulation practice [37] and is considered the ‘heart and soul’ [38] of simulation-based training. Raemer et al. [11] reviewed the current state of research on debriefing and provide a framework for further studies. A meta-analysis summarizing results from 2136 participants estimated the average positive learning effect of adding debriefings to trainings to 25%. In those cases in which the debriefing method and the training content were aligned with the learning needs of the participants (e.g. facilitated discussion in a team, focusing on
teamwork issues), positive effects were estimated to reaching 38%. Adding a visual aid, like video playback, however, was not seen as adding extra effects [39]. Tannenbaum and Cerasoli [39] speculate about artifacts in regard of the video use because debriefings that are researched might be so good anyway that adding video might not yield any extra benefit. Despite the negative findings, we recommend using video from our own experience as it offers such great potentials. A study found that it might not even be necessary to have an instructor guide the debriefing, if the group manages to stay on track while analyzing their performance [40]. In a post-test scenario, the two study groups showed comparable benefits of the debriefing, regardless of whether the debriefer led the debriefing or the group selforganized this process. When looking into the why debriefings work, it is important to see the integration of the debriefing into the larger context of the simulation setting [13]. The scenario, how it was introduced, or in which atmosphere the course was started, has a strong influence on how a debriefing will run. Kolbe et al. [41] describe a way to create a reflective setting during debriefings by combining ‘classic’ debriefing techniques with techniques from systemic therapy. They combine guided self-correction, the advocacy and inquiry technique [42,43], and circular questions (see Fig. 1 for an example). The approach redefines the combination of listening, talking and reflecting during a debriefing. As during scenarios, during debriefings also, instructors might not always only have the learning of the participants in mind. One classical example can be explained with the ‘please me’ driver known in transactional analysis [44]. The instructor in this case might strive to be pleased by the participants (Fig. 2). As a consequence, some difficult discussions might be avoided or goaloriented feedback might be withheld. A study found substantial differences in the official ratings of students in problem-based learning environments as compared with ‘unofficial’ ratings collected
Circular questions aim to describe an interaction of two or more persons as a further person would see it. For example, the debriefer might ask the anesthesiologist: When you came into the room and asked the nurse about the allergies of the patient – how do you think the patient perceived the answer of the nurse? Circular questions force the person answering to mentally change perspectives and see the world with different eyes. They can thus provide some unique insights.
FIGURE 1. Examples of circular questions. Adapted with permission from [44]. 716
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Please me!
Please like me!
Please - may I join?
FIGURE 2. Instructors (dotted) might be inhibited to make clear learning points by their wish to be pleased by the participants (striped).
retrospectively. The quantitative ratings correlated only to a medium level or lower with each other and the qualitative comments were almost in the opposite direction (vague and positive in the official version and more specific and more negative in the unofficial rating) [45]. Growing into a professional role as (simulation) facilitator might thus mean also to become aware of hidden motivations and finding a way to deal with them. Several attempts are made to assess the quality of debriefings. The first known to us was the Debriefing Assessment in Healthcare [46]. A new tool stems from the surgical context, the Objective Structured Assessment of Debriefing [47]. Both approaches are based on observing debriefings and assessing instructor behavior with rating scales. Although we do see a lot of benefits in assessing debriefings, we suspect that some issues discussed above – concerning the intention of an action – might not be captured with observational tools alone. There seems to be a ‘feeling’ that has some value to it, but that might be difficult to capture in figures and that nevertheless has value to be considered [48].
Designing courses and scenarios In this section, we reflect upon content of simulation scenarios and methodological issues when implementing them. Content aspects A common approach is to look at typical challenges and to replicate those in the simulator [49]. Scenarios could be selected based on their likelihood of occurrence, likelihood of an impact of training, the scope of the impact for the patient, the relatives and the healthcare professionals. We believe that optimizing ‘everyday’ challenges
such as anaphylaxis or perioperative bleeding may be superior to training rare events (e.g. malignant hyperthermia), even though they might not look and feel spectacular. Based on their frequent occurrence and on our assumption that optimizing everyday challenges will have positive impacts on crisis situations, we assume a large benefit of focusing on the whole range of possible scenarios. The debate about whether and why the simulated patient should ‘die’ during simulation took up speed again in conjunction with a discussion of scenarios that are overall psychologically challenging for participants [50–54]. We believe this debate is important, as it would open a potential new realm to use simulation in all those aspects that cannot be managed medically successful. In our view, it is beneficial to explore the role of simulation further to prepare healthcare professionals for their ‘dark moments’ [55–58]. The ‘Francis Report’ investigated challenges in a trust in the UK [59] that are also relevant for simulation-based training. Many of the challenges found were not directly related to the medical treatment in itself, but to the care provided to patients, before, during and after the actual treatment, addressing, for example, hygiene, nutrition and dignity. The key finding applicable to simulation is that scenarios might need to include those issues around the pure care, as they might be essential parts of the tasks to be done and can make or break the success. This would also imply to consciously design scenarios that include the handover of the patient between participants; the beginning and end of simulated cases might need to be moved, so that an overlap between cases is implemented. Psychological aspects of the needs analysis could help in revising the ‘boarders’ of scenarios to improve the inclusion of salient characteristics of the tasks simulated. Two recent books can direct the search for a psychological view on the challenges in healthcare. Gigerenzer and Gray describe and explain how healthcare professionals (mis)interpret much of the diagnostic information they handle every day [60]. Nobel prize winner Daniel Kahnemann takes a different angle on similar challenges and investigates how shortcuts in perceiving and thinking that make the human cognitive system so efficient can pose challenges in other instances [61]. These books and the publications to which they refer can serve as an invaluable source of inspiration and concrete guidance to design scenarios. One might hope that such a scenario could almost work like a vaccine: when participants experience the impact of cognitive biases and discuss the underlying mechanisms in the debriefing, they might be able to deal with
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them more effectively in clinical care – at least for some time, while the vaccine is fresh. Finally, we highly recommend two recent books by Nance [62 ,63 ]. A key message of the books we emphasize is to make patient safety and quality of care the core of any healthcare endeavor. One way of doing this is to rethink the professional distance between healthcare professionals and patients, allowing the negative impact that safety challenges have for patients to get much closer to the healthcare professionals than it in current practice. Reducing this distance for sure has advantages and disadvantages and practical implications could be investigated to some extent in simulation. &&
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Methodological aspects A recent meta-analysis was investigated, using part task training strategies [64 ]. The authors analyzed 37 studies investigating transfer of learning from a range of domains. Learners benefitted from part task training in those situations, in which the trained tasks needed to be performed in sequence in the actual work environment. In those instances, however, in which the actual task had elements that needed to be handled in parallel, it led to lower transfer of learning when these elements were separated during training. The learners did not learn the vital element of time sharing. In our view, this finding has an implication for the design of scenarios and courses in healthcare and implies that technical–medical issues should not be separated from nontechnical issues. A strategy to help learners balance both areas is called variablepriority-training, in which all the elements of the real-world complexity are preserved in training, but a clear focus is placed on a subset of those [64 ]. For example, it might be possible to run medically oriented scenarios of difficult airway management including issues of team interactions. Other scenarios might focus on team aspects, using difficult airway situations just as an example. One underlying assumption of current simulation practice is that people learn from errors. However, this seems to be more difficult than one might think. Loh et al. [65 ] discuss the impact of cognitive ability and personality type on the learning from errors. Higher clinical ability, the openness for making new experiences and less concern about doing everything correctly (conscientiousness) were related to benefits from error management trainings. Such trainings focus on encouraging exploring new options and describe the learning from errors as positive. It can be contrasted with error avoidance trainings that help learners to do the tasks correctly &
&
in the first place. An underlying theoretical assumption is that the focus on errors, whether in terms of management or avoidance, takes cognitive and emotional resources in itself. This way those learners would benefit, who either simply have more resources because of their higher abilities and those learners whose traits are in line with the focus on errors. Besides the focus on errors, the encouragement to explore a task was related to better transfer of learning. An interview study conducted with former participants of courses for advanced life support can be interpreted in a similar way [66 ], as the courses can be seen as examples of error avoidance type of training. Participants described the experience as helpful in the regard of getting firm guidance on practice by ‘black and white’ information about what is correct or incorrect in their treatment. The drill-type aspects of the training were reported to have strengths in groups of people who all worked according to the same principles and under standardized circumstances (e.g. all equipment needed actually available). Participants also reported challenges when applying the competences gained in the course in more complex and ill-structured real-world situations. The conclusion of the study was that these trainings have strengths in effectively learning how to treat certain types of clinical situations but had challenges in the application of those treatment algorithms in the ‘real’ world. &&
CONCLUSION We discussed selected connections between psychology and simulation in anesthesiology. Many psychological theories, frameworks and methods are relevant for optimizing the use of simulation – both, to optimize the psychology of simulation and using psychology within simulation to address known patient safety issues in a more effective way. It takes time and energy and much mutual learning to build fruitful co-operations between psychologists and anesthesiologists, but from our experience, the effort is well spent.
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Acknowledgements We thank our colleague Anne Lippert, MD, from the Danish Institute for Medical Simulation (DIMS) for valuable input for this paper. Conflicts of interest DIMS has a collaboration agreement with Laerdal, a manufacturer of simulators. DIMS receives research funding from the Laerdal foundation. DIMS is part of
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the EuSim group, providing faculty development programmes. The work on this manuscript was funded by institutional funds. Ralf Krage has no conflicts of interest.
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Technology, education, training and information systems 56. Jones JH, Treiber LA. When nurses become the ‘second’ victim. Nurs Forum 2012; 47:286–291. 57. McCay L, Wu AW. Medical error: the second victim. Br J Hosp Med (Lond) 2012; 73:C146–C148. 58. Manser T. Managing the aftermath of critical incidents: meeting the needs of health-care providers and patients. Best Pract Res Clin Anaesthesiol 2011; 25:169–179. 59. Francis R. Independent inquiry into care provided by mid Staffordshire NHS Foundation Trust January 2005–March 2009. The Stationery Office; 2010. 60. Gigerenzer G, Gray JAM. Better doctors, better patients, better decisions. MIT Press; 2011. 61. Kahneman D. Thinking fast slow. Farrar, Straus, and Giroux; 2012. 62. Nance JJ. Why hospitals should fly. Debolsillo; 2008. &&
A mind-changing experience to read this book and its successor ‘Charting the course’. If you work in the healthcare system, if you ever go there, if any of your relatives do – read this book.
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63. Nance JJ, Bartholomew K. Charting the course. Debolsillo; 2012. &&
A mind-changing experience to read this book. If you work in the healthcare system, if you ever go there, if any of your relatives do – read this book. 64. Wickens CD, Hutchins S, Carolan T, Cumming J. Effectiveness of part-task & training and increasing-difficulty training strategies: a meta-analysis approach. Hum Fac 2013; 55:461–470. Great guidance around fine tuning the sequences in your training sessions. 65. Loh V, Andrews S, Hesketh B, Griffin B. The moderating effect of individual & differences in error-management training: who learns from mistakes? Hum Fac 2013; 55:435–448. Makes the case that not one side fits all in terms of feedback. 66. Rasmussen MB, Dieckmann P, Barry Issenberg S, et al. Long-term intended && and unintended experiences after advanced life support training. Resuscitation 2012; 84:373–377. This review discusses potential negative long-term effects of using simulation.
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