Adult Learning and Simulation-Based Education

C H A P T E R

7 Adult Learning and Simulation-Based Education ´ tienne Rivie`re4,5,6 Gilles Chiniara1,2,3 and E 1

Educational Leadership Chair in Health Sciences Simulation Universite´ Laval & Universite´ Coˆte d’Azur, Que´bec, QC, Canada, 2Department of Anesthesiology and Intensive Care, Universite´ Laval, Que´bec, QC, Canada, 3Department of Anesthesia, CHU de Que´bec Universite´ Laval, Que´bec, QC, Canada, 4Department of Internal Medicine and Infectious Diseases, USN, Haut-Leveque Hospital, CHU de Bordeaux, Bordeaux, France, 5SimBA-S Simulation Center of Bordeaux, University of Bordeaux and CHU de Bordeaux, Bordeaux, France, 6Colle`ge Sante´ of the University of Bordeaux, Faculty of Medicine, Bordeaux, France

KEY CONCEPTS I

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Simulation-based education (SBE) is now being used at all levels of training and involves adult learners. While there is no learning process specific to adults, the contextual factors in their life which affect learning are different from those of children, and vary throughout their life. Adult learning is a complex, individual, and context-dependent process, with no single unifying theory.

Several strategies can be implemented in the instructional design of SBE, in response to the contextual factors affecting learning.

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Debriefing and feedback are essential to learning.

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Creating a safe environment and ensuring psychological safety are prerequisite conditions for learning.

Simulation-based education (SBE) is now being used at all levels of training in health care, including for continuing professional development (CPD),1,2 maintenance of certification,3,4 and faculty development.5 This includes the use of in situ simulation (Chapter 38:

Factors that affect learning relate to the learners’ experience, their needs, their motivation, their concerns and the learning process itself.

Clinical Simulation DOI: https://doi.org/10.1016/B978-0-12-815657-5.00007-3

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© 2019 Elsevier Inc. All rights reserved.

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In Situ Simulation) for continuing education.6 It is therefore often used as a training modality for adult learners. However, there is no predetermined age after which a person is considered an adult learner, and it is likely that even undergraduate and postgraduate healthcare students are indeed two different examples of adult learners. As such, understanding the educational theories and principles that underlie adult learning is paramount. This chapter aims to provide an overview of those principles, with the implications they have on the design and implementation of simulation-based activities.

7.1 IS THERE SUCH A THING AS AN ADULT LEARNER? It seems self-evident, on the face of it, that adults learn differently than children and adolescents; after all, they have a richer life experience and different aspirations. Consequently, it seems appropriate that adult learning be approached differently than children learning.7,8 In the 1980s, Malcolm Knowles popularized the term andragogy (from the Greek andr, meaning man, and agogos, meaning guide or leader) and contrasted it to pedagogy (from paidos, child, and agogos),9,10 which Knowles considered a more restrictive form of educational philosophy more suitable to children. While the term andragogy had originated in 19th-century Europe, Knowles was paramount in disseminating it, along with its underlying philosophy, to the point where he is usually considered the “father of andragogy.”11 The notion of andragogy has been undeniably embraced by the medicine and nursing education communities.

7.1.1 The Basic Assumptions of Andragogy When he initially described andragogy, Knowles presented four assumptions about

the adult learner, which were expanded to six in subsequent editions of his work.10 The following characteristics were used to describe adult learners: 1. The need to know: The adult learners must know why they need to learn before engaging with the learning process. 2. Self-concept: Adult learners move from a state of dependency on others to independency,9,12 as they take on responsibility for their own decisions. As such, they are selfdirected learners (SDL).13 In fact, for Knowles, that “adults can and do engage in SDL is now a foregone conclusion in adult learning research” (p. 185).10 3. Experience: Adults draw on a large reservoir of accumulated life experiences which can vastly differ from one individual to another.14 4. Readiness to learn: Adults become ready to learn what they need to know and do in order to deal with real-life situations and answer the demands of their everyday life. This occurs especially as they take on new social or life roles9 and as they enter into a social situation.11 5. Orientation to learning: Contrary to children who are subject-centered in school, adults are life-centered or problem-centered. They are motivated to learn if they perceive that their new knowledge and skills are useful to accomplish the tasks and problems they are faced with. They also favor immediacy, wanting to apply their new learning within a short timeframe.9,15 6. Motivation: Learning can be motivated either by external factors (e.g., social or work pressure, external reward) or by internal factors (e.g., the need to improve, to increase selfesteem). It is argued that, while children are more likely motivated by external factors, adults are usually motivated to learn by internal factors such as a desire for job satisfaction, greater self-confidence, and improving quality of life.13

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7.1 IS THERE SUCH A THING AS AN ADULT LEARNER?

7.1.2 The Problems With Andragogy Andragogy has been criticized since very early on. One of the oft-leveled criticisms against andragogy is that Knowles’ assumptions about adult learners are axiomatic and have not been subjected to rigorous testing.16,17 Such criticism led Knowles to reformulate the assumptions and amend some of his earlier assertions. However, this itself cast andragogy in a dubious light. As Jarvis asserted (p. 127)11: [. . .] the fact that [Knowles] reformulated the idea on a number of occasions illustrates the fact that each of the assumptions is open to considerable discussion.

Several aspects of andragogy were disputed (including semantical issues). As Norman asserted,16 the concept of SDL can be problematic because self-assessment is a prerequisite condition for SDL, yet humans— including physicians—are not good at selfassessment.18 21 Furthermore, Norman argued that, given the complexity of medicine, “it is difficult to conceive of a domain of learning where self-direction is less appropriate than in medicine” (p. 886).16 Another criticism of andragogy stemmed from the fact that there are few demonstrated fundamental differences in the way adults and children learn.17 For example, the assertion that children are more likely externally motivated compared to adults9,14 has not been entirely substantiated by research. In fact, external motivation may be harmful even in children since it decreases the impetus for learning when there is a low likelihood of reward or punishment.22 This is not to say that the original assertion is wrong, but that there is a great deal of controversy on this issue. Proponents of adult learning have risen to the defense of andragogy. Several of them (including Knowles10) argue that SDL does not

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mean that learners are entirely responsible for planning and implementing their learning and that teachers have no say in what they learn.13,23 Rather, the role of the educator or mentor is to guide the students to help them identify their weaknesses and orient their learning.13,24 Others further argue that the intent of andragogy is not to draw a clear dichotomy between adult learning (“andragogy”) and the learning of children and adolescents (“pedagogy”);25,26 this fact was recognized by Knowles in his later writings.10 Some educators see andragogy as a subset of pedagogy, the latter encompassing all the theory and practice of education.26 Others consider that, rather than being completely distinct, there is a continuum from pedagogy (children) to andragogy (adults), separated by the learners’ level of experience and their degree of control over their learning process.7 While we use the term pedagogy as encompassing the whole of education, we espouse the latter view: the learning process is arguably the same between adults and children; so are the factors that facilitate or hinder learning. It is the variables that constitute these factors (in other words, their content) that differ. The two most important differences are, as mentioned before, experience and level of control.7,27 For example, prior experience can facilitate or hinder learning, but the breadth and depth of experience is different between a child and an adult, and is thus more likely to affect the latter’s learning process; the difference lies not in the quality of experience, but in its scope.26 As another example, the act of “playing,” as a process and motivation for learning, is arguably as important to the adult learner as to the child, although the type of play activities might be contextually different (see Chapter 12: Learning Through Play, for a more thorough discussion of this topic in SBE). In short, the factors affecting learning are rooted in the context of the learner’s life.

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7.2 WHAT IS ADULT LEARNING? We consider adult learning as a “complex, context bound, and highly personal” process.9 While several theories for adult learning have been described (including andragogy,10 lifelong learning,11 and transformative learning28), no single theory encompasses the entire nature of adult learning.9,14 In fact, we would argue that there is no such thing as an adult learning theory, but rather a set of principles that arise from the context in which adults learn—and live—and which distinguishes their learning from children’s. This context stems from the learners’ personal characteristics (such as the physiological changes related to aging and the life cycle phases) and situational characteristics (part-time learning instead of full-time learning, voluntary instead of compulsory learning).27 Rather than an arbitrary distinction based on age, we consider adult learning as the “lifelong process of continuing inquiry” (p. 268).15 This process of learning evolves throughout life based on the contextual reality of the learners.11,29,30

7.3 FACTORS THAT AFFECT LEARNING In this section, we will delve into the contextual factors that affect the learning experience, including that of an adult, by dividing them into five categories: experience, needs, motivation, concerns, and process.14 We will highlight the way they affect teaching and learning in SBE (Table 7.1). The purpose of this chapter is not to cover extensively all factors affecting learning by adults, but to provide an overview of some of them. Readers are also referred to Chapter 8, Theory for Practice: Learning Theories for Simulation, for an overview of learning theories and to

Chapter 6, Adapting Learning in a Simulated Environment and Chapter 9, SimulationBased Education and the Challenge of Transfer, for a cognitive approach to learning and transfer. We recognize that some of the strategies suggested for integrating adult learning principles into SBE might be difficult to implement. The suggestions are not entirely prescriptive, however, and should be adapted to the reality of the learning institution, its culture, and its learners.

7.3.1 Experience Experience creates and shapes learning by forcing an individual to seek solutions to new problems. This is why experiential learning methods, of which SBE is a prime example, have become a mainstay of modern education. By being active participants, by building hypotheses based on lived experiences and testing those strategies in future problems, experiential methods become a powerful tool for learning.31 Experience is essential to learning since prior knowledge serves as a foundation for structuring new learning and might be the most important factor influencing learning.32 It provides a rich resource from which the learners draw to anchor and create new knowledge. It makes learning more meaningful.8 This means that accumulated knowledge and experience must be connected to new information.7 In SBE, this can take many forms. New scenarios may be designed based on the learners’ prior experiences. In an in situ setting, for example, a specific case to which the learners were exposed could be reproduced in simulation. It is also advisable that scenarios and debriefing make explicit references to knowledge acquired in prior scenarios and simulation activities. Rather than merely offering multiple simulation activities with no commonalities or connections, a thematic thread

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7.3 FACTORS THAT AFFECT LEARNING

TABLE 7.1 Factors That Affect Learning and the Strategies That Should be Implemented for Effective SimulationBased Education (SBE) Factor

Principle

Strategies for SBE

Experience

New knowledge is constructed on prior knowledge

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Learners will have very different individual experiences

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Experience creates individual biases and habits

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Needs

The most pervasive learning is selfinitiated

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Learners do not always identify their learning needs

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Learning is not the only need

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Motivation

Try to ensure homogeneous learner groups Provide a common knowledge base Provide thorough information about the training session, including why it is needed; provide a thorough prebriefing Consider such biases during debriefing The simulation institution should encourage efforts for professional development that are initiated by the healthcare professionals and/or students themselves Offer a diverse range of SBE activities and/or have representatives of the learners on the curriculum committee and/or involve learners in instructional design Perform a thorough process of needs assessment Design the SBE activities around the identified needs of the learners Use the first simulation scenario to identify the gaps (but inform the learners beforehand) Attend to the learners’ physiological needs (food, frequent breaks, seating arrangements, etc.) Attend to the learners’ safety needs (storing belongings, safety during simulation, emotional safety)

Needs change in time

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Implement a quality assessment process for simulation activities

Learners may be motivated by external factors

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Involve the learners in the process of needs assessment Inform the learners of the needs assessment (during or prior to prebriefing) Adopt an approach of the educator as a guide rather than as a teacher

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Concerns and safety

Design new scenarios based on the learners’ prior experiences (including simulation experiences) Make explicit references to prior scenarios and activities, both in the scenarios and in debriefing Recall prior knowledge (through a pretest, watching didactic material including prior exposures to simulation, or asking about prior exposures to similar situations during debriefing)

Learners are internally motivated to learn by problems they encounter

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Design scenarios based on real-life events which are meaningful to the learners (specific or general problems)

Immediacy of application fosters motivation

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Consider in situ simulation and just-in-time training

Participants may experience anxiety for different reasons

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Identify and acknowledge the participants’ sources of anxiety (Continued)

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TABLE 7.1 (Continued) Factor

Principle

Strategies for SBE

Participants are vulnerable during SBE

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Roles must be clearly established

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Process

Establish a safe learning environment (a “safe container”) through multiple means (see text) Carefully consider the pros and cons before allowing the death of the patient Ensure the availability of psychological support for learners after simulation Establish clear institutional guidelines and policies to ensure psychological safety (including the policy related to the patient’s death) Present the roles of the simulation team (and standardized patients/actors) during prebriefing Avoid participating in the simulation if you are the main debriefer “De-role” members of the simulation team (except standardized patients/actors) at the beginning of debriefing

Adult learners are independent

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Adopt a self-directed and learner-centered approach by allowing participants a degree of control in their simulation experience (by involving them in needs assessment or allowing them to control debriefing, for example)

Multiple learning modalities are more effective than single modalities

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Complement simulation with other instructional media and methods (reading, videos, reflective journals, educational prescriptions, etc.)

Feedback is essential for learning

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Provide feedback from multiple sources (instructors, peers, standardized patients, self) Debriefing should be facilitated by trained debriefers Debriefing should follow a structured framework

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Learners must develop their metalearning and metacognitive abilities

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Train them in SBE and debriefing, and involve them in SBE activities

See text for additional details.

must be woven throughout the simulation activities, in a coherent curriculum. New activities must start where others ended. In order to construct new knowledge, prior learning must be recalled before any simulation session. This retrieves prior knowledge from long-term memory to working memory, allowing for links to form with the new knowledge that is acquired.33 The recall of stored information can be done in SBE through several means: administering a pretest to the learners; providing them with reading material before simulation; or asking learners to watch

videos on the topic at hand, including any relevant prior simulation scenarios that were filmed and in which they participated (or not). Of course, enquiring about prior exposures to situations similar to the simulation scenario might be a great way of activating prior knowledge early in a debriefing. Acquiring a lot of life experience means that individuals will present to a learning activity with a wider range of individual differences. This heterogeneity will likely increase with age.34 Trying to ensure more homogeneous groups in terms of experience might alleviate

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this concern.29,35 Importantly, the methods described above to activate prior knowledge will also “level the playing field” by removing some of the knowledge discrepancies between individuals in the learners’ group. Experience also creates biases that can inhibit or shape new learning. Older learners may be set in their ways and will have their own individual biases,7,29 including about how education should occur.8 Providing thorough information about the training session, including the reason why it is needed, may help address some of these concerns. This begins with choosing appropriate recruitment material that clearly identifies the reasons for training. A thorough prebriefing is also key (see Chapter 33: Prebriefing and Briefing). Finally, debriefers should take into account the learners’ possible biases, and aim to uncover their specific motivations and frames of reference (see Chapter 35: Debriefing for the Transfer of Learning: A Cognitive Approach). Advocates of experiential learning methods will often highlight the importance of adapting the instructional methods to the participants’ “learning styles,” which are said to be based on childhood learning patterns.36 There are several tools that purport to measure an individual’s preferred learning style.8 The most frequently used method categorizes individuals as visual, auditory, and kinesthetic learners. However, it is unclear whether learning styles are indeed a reflection of personality or experience.35 In fact, the preferred learning methods are likely to vary, even for a single individual, depending on the time and purpose of learning.14 There is currently a large debate in the education literature on whether so-called “learning styles” actually exist.37,38

7.3.2 Needs The answer to the question “What’s in it for me?” drives the learner’s efforts toward the

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acquisition of knowledge and skills.7 For individuals, especially adults, to engage in learning, they must feel the learning activity is relevant and useful to them. This occurs when they recognize the discrepancy between their current and their desired proficiency.34 The level of proficiency they aim for can be born from individual aspirations, the expectations of others, or the vagaries and problems of real life. As such, learners are “relevancy-oriented”: their need for learning stems from the problems they encounter in their everyday life.7,14 This need can, in turn, drive efforts toward SDL. This kind of self-initiated learning may be the most pervasive.7 In SBE, this means designing CPD activities and other simulation activities in response to a request by the learners themselves. The offer of simulation activities must be diverse enough that participants might choose training activities that fulfill their needs. Alternatively, representatives of the learners may sit on a simulation institution’s curriculum committee (or its equivalent). The learners’ representatives may also be involved in the instructional design (curriculum development) efforts.39 However, the learners’ educational needs are not always obvious to them and must often be explored.15 As previously discussed, human beings are not adept at self-assessment, and there may be a large discrepancy between perceived and actual needs. Hence, a process of needs assessment is crucial in instructional design for SBE (or, indeed, any other learning activity), and must inform—thus precede—the determination of learning objectives and the design of the educational intervention and/or simulation scenario.40 A thorough process of needs assessment should identify four types of needs: (1) felt needs, which are the learners’ wants; (2) normative needs, which are the standards dictated by experts and/or administrators; (3) expressed needs, which are demonstrated by the consequences of the learners’ actions; and

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(4) comparative needs, which are the needs expressed by other groups with similar characteristics.41 There are several methods for needs assessment.34,42,43 Their description is beyond the scope of this chapter, but they may include such methods as surveys and self-assessments (felt needs and/or comparative needs), critical incident analysis, hospital records, morbidity and mortality data, audits, performance assessment (expressed needs), market study research (comparative needs), literature review, accreditation process, and guidelines (normative needs). It is essential that learners be involved in the process of needs assessment and/or informed of it to ensure convergence of actual and perceived needs. Finally, in determining the learning needs, educators must seek out and consider the needs in the cognitive, affective, and psychomotor domains (i.e., they must go beyond knowledge).15 It is noteworthy that simulation itself can identify gaps in the learners’ skills and knowledge. A simulation-based activity may thus inform a subsequent activity. Moreover, the first scenario of a simulation session might be used as a way to allow the learners to identify their own performance gap, ensuring a better engagement in the rest of the activity. This must not, however, be done to the detriment of their emotional safety (see below): an exploratory scenario should not be a method of “putting them down” but a sincere effort to identify gaps in performance and proficiency. The learners should be informed beforehand when simulation is used specifically to highlight such gaps. Learning needs are not the only needs that the simulation educator should consider: humans have many needs (or, according to Abraham Maslow,44 a hierarchy of needs), starting with basic needs such as physiological and safety needs.45 Physiological needs include the need for water, food, warmth, rest, etc. Providers of simulation training must cater to these needs (see also Chapter 13: Simulation as

a Social Event: Stepping Back, Thinking About Fundamental Assumptions). A training session should provide refreshments and, when appropriate, meals or snacks. Frequent breaks should be mandatory, especially in an activity as stressful as simulation.46,47 Seating arrangements should be comfortable. The activity’s duration should be adequate, neither too long nor too short. A careful consideration of the logistics of the activity is aimed at answering physiological needs.7 Safety needs include both physical and psychological safety. The latter will be expanded on below. As for physical safety, it starts by ensuring that the simulation environment is safe for learners. If live defibrillators are used, learners should be informed of that fact and appropriate preemptive measures should be put in place to avoid any accident. First aid protocols should be put in place (and regularly tested). The learners’ belongings must be safely stored so as to avoid the risk of theft. Making the environment safe for learners is not only conductive to learning, it is also a human and fundamental requirement. Finally, educators should remember that needs (both learning needs and other needs) are satisfied only temporarily and must be addressed repeatedly.48 This should be the impetus for a thorough quality assessment process for simulation activities.

7.3.3 Motivation As previously mentioned, learners can be motivated by external and internal factors. Sources of motivation include (1) social relationships, (2) external expectations, (3) social welfare, (4) personal advancement, (5) escape or simulation, and (6) cognitive interest.7,8 The context of the adult learners renders them more likely to have internal motivation to learn: they are more likely to choose a CPD

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activity for career advancement, a desire to improve, or an identified proficiency gap. Children, on the other hand, are more likely to have external pressures to learn, such as mandatory school and familial pressures. This, however, is not necessarily always the case: maintenance of certification programs and continuing education activities are now mandatory for most, if not all, health professionals. As such, while the choice of CPD activity may be in response to internal motivations, the push for lifelong learning is, at least partly, the result of external pressures by regulatory authorities, insurance companies, and/or administrative bodies. The true source of motivation is further likely to change throughout a professional’s life.29 Simulation educators should be cognizant of the factors that motivate a given group of learners. Participants may be less willing to learn if the activity is implemented at the request of the department chair rather than that of the individuals themselves. Mandatory activities are also less likely to be embraced by participants. Involving the learners in the needs assessment might alleviate some of these concerns. A thorough prebriefing, a good attitude from the educators and personnel, and sensitivity during debriefing will also help convince the learners that they will benefit from the activity. They are more likely to engage with the activity if they perceive the educator as a guide or mentor rather than an all-knowing teacher. Physicians are internally motivated to learn in response to specific problems (e.g., problems encountered in their contact with patients) and general problems (e.g., updates on bodies of knowledge and skills).49 To foster this motivation (which is arguably better than external motivation), it is essential for simulation scenarios to be based on real-life situations and on events that are meaningful to the learners.7,14 These situations could be drawn from the specific or general problems

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encountered by the physicians and/or other healthcare professionals. Finally, learners are motivated when their learning can be immediately applied in their professional life.15 Educators should consider designing scenarios that they are highly likely to encounter in their workplace. Conversely, educators can design simulation activities for justin-time training (situation-related; see Chapter 38: In Situ Simulation), usually—but not always—through in situ simulation.50,51 Such activities involve simulation scenarios created from the records of patients actually on the care unit (or likely to be admitted very soon). Chapter 11, Motivational Dynamics in Simulation Training, provides more thorough information on the importance of motivation in learning.

7.3.4 Concerns and Psychological Safety When embarking on a learning endeavor, adult learners bring with them not only needs and motivation, but also specific—and varied—concerns: fear of committing major errors, fear of peer judgment, anxiety over declining abilities, and fear of technology. An issue specific to healthcare experiential learning methods such as simulation is the likelihood of committing major errors and/or causing the death of the patient. Learners should be informed during prebriefing—and this should be repeated during debriefing—of the prevailing philosophy in SBE: that errors are not to be feared but should be considered as markers for areas of potential improvement (usually within a team), rather than individual shortcomings. Patient death is a thorny issue and is still being debated.52,53 It can be allowed in SBE under certain conditions54 which are expanded on in Chapter 23, A Systematic Approach to Scenario Design, but allowing the patient to die should be the result of a deliberate and careful consideration by the learning

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institution. In any case, the scenario should be designed with multiple pathways, including methods to put a scenario “back on track” if the participants’ actions threaten its outcome. Finally, consideration should be given to providing the learners with psychological support following simulation, should they need it. This support can be provided by the local student counseling service or other similar resources, provided these resources are informed beforehand of the nature and peculiarities of SBE. The availability of psychological support should be made clear during prebriefing. While, anecdotally, we are not aware of any student needing such support in more than 12 years of simulation in our institution, it is unacceptable for even a single learner to have difficulty obtaining psychological support that he or she might need. Adult learners may have concerns regarding their aging abilities, especially if they have not trained in a while.14 This issue is particularly pervasive in SBE. An early study showed that 25% of anesthesiologists surveyed expressed concerns about performing in front of peers or educators.55 Such concerns are likely to be even more prevalent in in situ simulation since the participants are work colleagues; they may fear that errors or shortcomings on their part will mar their relationship or affect their colleagues’ perception of their own abilities. Other barriers to SBE have been identified by a review in nursing education, including a fear of technology (“technostress”).56 While the sources of concern and anxiety in SBE are not well documented, its very nature as a collective experiential learning method—with the added risk of committing potentially fatal errors—requires that special attention be given to the establishment of a climate that is suitable to learning and that ensures psychological safety.7,15,34 Such safety is essential—and is a recognized standard in SBE57—because participants in simulation are vulnerable: they are (often) not in their usual

environment; they may not be with their usual colleagues; given the frequent emphasis on crisis situations and human factors (see Chapter 25: Crisis Resource Management and Nontechnical Skills: From Individuals to Teams, From Danger to Safety), the nature of scenarios in immersive simulation makes them susceptible to errors and mistakes; and, finally, they put their self-worth and professional competency on the line. Rudolph, Raemer, and Simon58 have identified four practices to establish a “safe container”: (1) clarifying expectations; (2) establishing a “fiction contract” with participants; (3) attending to logistical details; and (4) declaring and enacting a commitment to respecting learners and concern for their psychological safety. These practices include the need to guarantee confidentiality regarding the participants’ performance. Some of these elements are summarized in Chapter 33, Prebriefing and Briefing. More broadly, citing K. Patricia Cross’ work,27 Glicken suggested five elements to create safety in learning:15 1. Trust in the competence of the educator: Educators participating in simulation should make their experience in SBE known during or before prebriefing. They should further be specifically trained in SBE, including debriefing.57 2. Trust in the feasibility of the objectives and their relevance: The needs assessment should be explained to the learners. The objectives should also be disclosed to the participants before the simulation. If this is not possible (e.g., because it risks revealing the content of a scenario), participants should at least be informed of the overall goals and/or theme of the activity. 3. Encouraging small groups to find their voices: Educators should favor small groups in SBE. Debriefing must be learner-centered and encourage participation.

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4. Trust in the sequence of activities: Consistent with the mastery learning approach,59 61 simple tasks should be learned before complex ones. Through sequencing and reinforcement, individuals can progressively and safely be led to learn highly complex tasks. 5. Nonjudgmental environment: The educators should be respectful of the learners, empathic, and alert to their needs.7,15,29 They should engage learners from a stance of curiosity rather than one of judgment. In this we agree with Rudolph and collaborators that debriefing with “good judgment” is better than both judgmental and nonjudgmental debriefing.62 Alan Knox34 also suggests several methods to establish a good climate for adult learners, which are complementary to those described here, and can be adapted to SBE: I

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Arrange for introductions, ice-breakers, name cards, and/or other methods to help participants become acquainted with each other and with the simulation educators and staff. Encourage participants to say something about their background and provide their reasons for participating, if they are not obvious. Provide comfortable and adequate physical facilities. Clarify the procedures and logistics of the session. Help participants formulate or modify goals and objectives. Encourage the sharing of experiences and insights during debriefing.

As a final important note, it is essential, in creating a safe and effective learning environment, that the different roles (those of the learners, educators, and other facilitators) be clearly defined.15 This is especially true in SBE where educators and other simulation

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personnel may take on different roles during the simulation (family, colleagues, etc.) which could blur the roles during debriefing. We strongly encourage the main debriefer not to take part in simulation in a different role. In any case, when members of the simulation team who participate in debriefing have taken on a role different from their own during simulation, they must be “de-roled” at the start of debriefing. Standardized patients and actors may also be called upon to participate in debriefing, especially to share their insight into their relation and communication with the learners during the simulation. They are not “de-roled” and should participate in character, speaking in the first person.63 The reason for having actors participate in debriefing and their role during debriefing should be divulged to the learners at the beginning of the simulation session, during prebriefing.

7.3.5 Process The learning process itself should be adapted to increase its effectiveness, especially when it involves adult learners. As discussed previously, SDL has been promoted by Knowles as central to adult learning.10 In SDL, individuals should set their own goals, identify the learning resources and select appropriate learning strategies, integrate material from different sources, and monitor their achievement.30 This is arguably unrealistic in health care. It requires adaptability that the academic institutions cannot reasonably provide. Because of the difficulty in selfassessment, setting goals and determining what needs to be learned is also difficult. For Norman, “what is to be learned as opposed to how it is to be learned should be nonnegotiable (at least at the level of core competencies)” (p. 888).16 While we do agree with such a stance for core competencies, we generally

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agree with Taylor24 that the objectives and content of learning should be dependent on the wants of the students, but also on the requirements of the curriculum and the needs of the patients. Learning is not entirely selfdirected: it is self-initiated and guided by the educator who can at least identify the starting point.7,9 Of course, SDL is difficult for adults who lack independence, confidence, internal motivations, or resources;9 those adults would benefit more from instructor-led training. As such, SDL is better defined as “a goal towards which learners strive so that they become able to accept responsibility for their own learning” (p. 213),12 rather than a sine qua non condition of all learning experiences. In SBE, leaning toward SDL means adopting a learner-centered approach, by allowing them some control over their learning experience. This increases their “perception of controllability,” enhancing in turn their motivation.64 This control may take the form of learners’ involvement in the needs assessment, their participation in designing objectives, having them describe experiences that were significant for them which could be reproduced in simulation, and giving them at least partial control of debriefing (after appropriate training). Much has been made of learning styles in adult learners but, as previously discussed, their very existence is still unsupported. However, research has shown that single learning modalities are unlikely to change the practices of healthcare professionals. The most effective learning methods are those that involve several modalities and multiple exposures.65 68 Thus, educators should vary the educational experiences.7 Even simulation is unlikely to be successful in changing practices and patient outcomes alone; it should be complemented by other educational modalities and methods. Such modalities may include reading, videos, reflective journals,69,70 and educational prescriptions71 given to participants at the end of a debriefing or training session. “It can’t be only simulation.”

The need for feedback and debriefing cannot be overstated (see Chapter 34: Debriefing Frameworks and Methods and Chapter 35: Debriefing for the Transfer of Learning: A Cognitive Approach). Feedback is a mainstay of learning, including adult learning.72 Proponents of SBE would argue that the bulk of learning occurs during debriefing rather than simulation itself. We encourage providing feedback from multiple perspectives (self, peer, instructor, and standardized patient)—for example, by using active observers that watch simulation from a distance with feedback in mind, then participate in debriefing (see Chapter 11: Motivational Dynamics in Simulation Training)—and by involving all simulation participants in debriefing. Moreover, as previously stated, debriefing should be facilitated by educators trained in its techniques and process, and should be based on a structured framework.57 Finally, in order to increase motivation and foster effective SDL, adult learners should learn how to learn.25,29 Indeed, “the most important learning for all adults is learning to learn—the skills of self-directed inquiry” (p. 268).15 Developing the learners’ “metalearning” abilities (learning how we learn)25 should be coupled with attempts to heighten their metacognitive abilities (understanding how we think) to complement the learners’ existing knowledge and skills. Examples of helping learners develop their metalearning and metacognitive abilities include training them in the theory and practice of SBE and debriefing, and allowing them to facilitate debriefing of their peers or other groups of learners.

7.4 CONCLUSION While adults and children share the same learning process, the context in which their training takes place differs. Those contextual factors come to bear on their acquisition of

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new knowledge and skills. In this chapter, we provided an overview of those factors and how they should affect the way we design and implement SBE. Most of the techniques described here are not limited to adult learners but are particularly well-suited to them. One must remember, however, that there is no set age at which an individual becomes an “adult learner.” Students in health care have many of the same contextual constraints as adult learners and would benefit from the strategies described here.

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