Johanna Dahlberg

Enacting simulation: A sociomaterial perspective on students' interprofessional collaboration.

ABSTRACT Full-scale simulation exercises are becoming more common as an educational feature of the undergraduate training of health professionals. This study explores how interprofessional collaboration is enacted by the participating students. Practice theory is used as the theoretical framework for a field study of two naturalistic educational settings, when medical and nursing students come together to practice in a simulated emergency situation, where a manikin is replacing the patient. Eighteen sessions of simulations were observed, and data were collected through standardised video recordings that were analysed collaboratively. To ensure transparency and scientific rigour, a stepwise constant comparative analysis was conducted, in which individual observations within and across single video recordings were compared, negotiated and eventually merged. The findings show that the student teams relate to the manikin as a technical, medical, and human body, and that interprofessional knowings and enactments emerge as a fluid movement between bodily positioning in synchrony and bodily positioning out of synchrony in relation to the sociomaterial arrangements. The findings are related to contemporary theorisations of practice comprising an integrated view of body and mind, and it is discussed how the findings can be used in simulation exercises to support participants’ learning in new ways.

Debriefing practices in interprofessional simulation with students: a sociomaterial perspective

BackgroundThe debriefing phase is an important feature of simulation activities for learning. This study applies a sociomaterial perspective on debriefing in interprofessional simulation with medical and nursing students. Sociomaterial perspectives are increasingly being used in order to understand professional practice and learning in new ways, conceptualising professional practice as being embodied, relational and situated in sociomaterial relations. The aim of the study is to explore how debriefing is carried out as a practice supporting students’ interprofessional learning.MethodsEighteen debriefing sessions following interprofessional full-scale manikin-based simulation with nursing and medical students from two different universities were video-recorded and analysed collaboratively by a team of researchers, applying a structured scheme for constant comparative analysis.ResultsThe findings show how debriefing is intertwined with, and shaped by social and material relationships. Two patterns of enacting debriefing emerged. Debriefing as algorithm was enacted as a protocol-based, closed inquiry approach. Debriefing as laissez-faire was enacted as a loosely structured collegial conversation with an open inquiry approach.ConclusionThe findings indicate that neither an imposed structure of the debriefing, nor the lack of structure assured interprofessional collaboration to emerge as a salient topic for reflection, even though that was an explicit learning objective for the simulation.

Learning professional practice through education

In this chapter we discuss a case of professional learning in higher education with a particular focus on health care. We focus in particular on what aspects of professional education become visible if we shift our viewpoint from a cognitive learning perspective on professional education, to a practice theory perspective, viewing this case of professional education as a practice, or a set of practices, in itself. Introducing a practice theory perspective on pedagogy on professional health care education might allow a new gaze on a field that for a long time been has been dominated by cognitive discourses about how to improve students’ learning. We focus on how the socio-materiality of professional practice is realised within the curriculum of the professional programs through three cycles, the courses Health, Ethics and Learning, part 1 and 2, and the Student Training Ward. We show how the relations between different sets of actors are connected, both as important mediating conditions through broader societal discourses, national legislation, local institution and organisation, as well as in terms of how every day educational practice is enacted. The chapter highlights the need for serious consideration of how to use the material arrangements in the educational setting to enable a collaborative practice to unfold.

Improvement of quality and safety in health care as a new interprofessional learning module – evaluation from students

Background Interprofessional teamwork is in many ways a norm in modern health care, and needs to be taught during professional education. Description This study is an evaluation of a newly introduced and mandatory learning module where students from different health profession programs used Improvement of Quality and Safety as a way to develop interprofessional competence in a real-life setting. The intention of this learning module was to integrate interprofessional teamwork within the students’ basic education, and to give students a basic knowledge about Improvement of Quality and Safety. This report focuses on evaluations from the participating students (n=222), mainly medical and nursing students. Materials and methods To evaluate this new learning module, a questionnaire was developed and analyzed using a mixed methods design, integrating both qualitative and quantitative methods. The evaluation addressed learning concepts, learning objectives, and interprofessional and professional development. Results and conclusion A majority of students responded positively to the learning module as a whole, but many were negative towards specific parts of the learning module and its implementation. Medical students and male students were less positive towards this learning module. Improvements and alterations were suggested.

Method matters: impact of in-scenario instruction on simulation-based teamwork training

BackgroundThe rationale for introducing full-scale patient simulators in training to improve patient safety is to recreate clinical situations in a realistic setting. Although high-fidelity simulators mimic a wide range of human features, simulators differ from the body of a sick patient. The gap between the simulator and the human body implies a need for facilitators to provide information to help participants understand scenarios. The authors aimed at describing different methods that facilitators in our dataset used to provide such extra scenario information and how the different methods to convey information affected how scenarios played out.MethodsA descriptive qualitative study was conducted to examine the variation of methods to deliver extra scenario information to participants. A multistage approach was employed. The authors selected film clips from a shared database of 31 scenarios from three participating simulation centers. A multidisciplinary research team performed a collaborative analysis of representative film clips focusing on the interplay between participants, facilitators, and the physical environment. After that, the entire material was revisited to further examine and elaborate the initial findings.ResultsThe material displayed four distinct methods for facilitators to convey information to participants in simulation-based teamwork training. The choice of method had impact on the participating teams regarding flow of work, pace, and team communication. Facilitators’ close access to the teams’ activities when present in the simulation suite, either embodied or disembodied in the simulation, facilitated the timing for providing information, which was critical for maintaining the flow of activities in the scenario. The mediation of information by a loudspeaker or an earpiece from the adjacent operator room could be disturbing for team communication.ConclusionsIn-scenario instruction is an essential component of simulation-based teamwork training that has been largely overlooked in previous research. The ways in which facilitators convey information about the simulated patient have the potential to shape the simulation activities and thereby serve different learning goals. Although immediate timing to maintain an adequate pace is necessary for professionals to engage in training of medical emergencies, novices may gain from a slower tempo to train complex clinical team tasks systematically.

Ten years of simulation-based shoulder dystocia training- impact on obstetric outcome, clinical management, staff confidence, and the pedagogical practice - a time series study

BackgroundTo assess the impact of 10 years of simulation-based shoulder dystocia training on clinical outcomes, staff confidence, management, and to scrutinize the characteristics of the pedagogical practice of the simulation training.MethodsIn 2008, a simulation-based team-training program (PROBE) was introduced at a medium sized delivery unit in Linköping, Sweden. Data concerning maternal characteristics, management, and obstetric outcomes was compared between three groups; prePROBE (before PROBE was introduced, 2004–2007), early postPROBE (2008–2011) and late postPROBE (2012–2015). Staff responded to an electronic questionnaire, which included questions about self-confidence and perceived sense of security in acute obstetrical situations. Empirical data from the pedagogical practice was gathered through observational field notes of video-recordings of maternity care teams participating in simulation exercises and was further analyzed using collaborative video analysis.ResultsThe number of diagnosed shoulder dystocia increased from 0.9/1000 prePROBE to 1.8 and 2.5/1000 postPROBE. There were no differences in maternal characteristics between the groups. The rate of brachial plexus injuries in deliveries complicated with shoulder dystocia was 73% prePROBE compared to 17% in the late postPROBE group (p > 0.05). The dominant maneuver to solve the shoulder dystocia changed from posterior arm extraction to internal rotation of the anterior shoulder between the pre and postPROBE groups. The staff questionnaire showed how the majority of the staff (48–62%) felt more confident when handling a shoulder dystocia after PROBE training. A model of facilitating relational reflection adopted seems to provide ways of keeping the collaboration and learning in the interprofessional team clearly focused.ConclusionsTo introduce and sustain a shoulder dystocia training program for delivery staff improved clinical outcome. The impaired management and outcome of this rare, emergent and unexpectedly event might be explained by the learning effect in the debriefing model, clearly focused on the team and related to daily clinical practice.

Continuing professional development: pedagogical practices of interprofessional simulation in health care

ABSTRACT The increasing complexity of health care practice makes continuing professional development (CPD) essential for health care professionals. Simulation-based training is a CPD activity that is often applied to improve interprofessional collaboration and the quality of care. The aim of this study is to explore simulation as a pedagogical practice for the CPD of health care professionals. Specifically, the study focuses on how a professional development activity, the simulation, is enacted to support interprofessional collaboration and learning. A practice theory perspective is used as the theoretical framework. In this, the professional practice is conceptualised as being embodied, relational and situated in sociomaterial arrangements. Ten introduction and reflection sessions following interprofessional full-scale manikin-based simulations with professionals were video-recorded. The recordings were analysed following a stepwise qualitative collaborative approach developed for the purpose. The key findings suggest that the professional competence activity is enacted and interconnected with and governed by historical traditions of institutional teaching practices as well as simulation practices. Despite the intentions of team and interprofessional training, the institutional teaching and simulation practices constrain and hinder the intended outcomes of professional development in interprofessional collaboration.

Observing of interprofessional collaboration in simulation: A socio-material approach.

ABSTRACT Simulation exercises are becoming more common as an educational feature of the undergraduate training of health professionals. Not all students participate in these activities, but are assigned as observers of the actual simulation. This article presents a study that explored how social-material arrangements for observation of interprofessional collaboration in a simulated situation are enacted and how these observations are thematised and made relevant for learning. The empirical data consisted of 18 standardised video recordings of medical and nursing students observing their peer students simulate. Practice theory is used to show how observation is embodied, relational, and situated in social-material relations. The findings show two emerging ways of enacting observation—proximate observation and distant observation. The enactments are characterised by different socio-material arrangements concerning the location where the simulation took place and its material set-up as well as embodied “doings” and “relatings” between the observing students and instructors. The observing students are participating in a passive, normative position as an audience and as judges of what is correct professional behaviour.

From 'there' to 'here' to 'elsewhere: Enacting debriefing in interprofessional medical education simulation

Hypothesis Simulation is gaining international interest as a way to arrange a safe environment for practicing clinical, communicative and interprofessional competence in professional education within health care. However, simulation was originally developed to support and train professionals. The application of medical simulation in interprofessional education for students is still underresearched and undertheorised.1 Recent research and theory argue that professional learning in simulation is embodied, relational, and situated in social-material relations.2-3 Research on how instructional design of simulation as an integrated part of professional curricula support student learning is needed,4 as well as research focusing on what the relevant characteristics of debriefing that lead to effective learning are.1 The aim of this study is to explore the enactment of debriefing as a support for learning in interprofessional medical education simulation. Methods This paper draws on findings from a large research project conducted by research environments at Linköping University (LiU), Karolinska Institute (KI) and University of Gothenburg (GU), Sweden. The data have been collected by standardised video recordings of all phases in the simulation (briefing, simulation and debriefing phases). A total of 30 simulation sessions were video-recorded; 10 sessions by each research team. Out of these recordings, 13 simulation sessions were professional teams and 17 sessions were nursing and medical students simulating as a compulsory part of their education in the last semester before graduation. The student sessions are around 18 hours of recordings and altogether 106 students, 71 females and 35 males, participated in the simulation either as active participants in the simulation or as observers. 66 were nursing students and 40 were medical students. The research project has been ethically approved by Linköping University, Sweden (Dnr 2012/439-31). Results A framework for the analysis of the video-recordings was developed on the basis of socio-material theory, with a particular focus on interprofessional collaboration. Sayings, doings and relatings in the debriefing with regard to specific activities or events during the sequence of the scenario were noted through ethnographic field notes and selected segments were transcribed.5 A purposeful constant comparative qualitative analysis6 was made in three steps comparing sequences of the scenario 1) within a single video-recording 2) between different video-recordings of the same scenario 3) between video-recordings of different scenarios. The findings suggest that interprofessional learning in medical education simulation can become jeopardised in the debriefing. Three interrelated aspects of lacking support for learning were identified, a) debriefing as algorithm or as laisséz-faire, b) neglect of team performance as a topic for reflection, and c) time constraints. Conclusion The results raise questions whether debriefing in medical simulation as modeled on training of qualified health professionals provides a useful framework applied in undergraduate education with students learning to become health professionals. The experiences of the simulation ‘there’ are intended to become re-contextualised in the debriefing ‘here’. Our findings indicate that the socio-material arrangements of the debriefing instead risk taking the students ‘elsewhere’. Structure or lack of structure of the debriefing seem both to jeopardise the support of interprofessional learning or even overlook interprofessional collaboration as a topic for reflection. The time constraints of the complex logistics of arranging interprofessional simulation-based education as a regular curricular activity for large classes can potentially turn debriefing into a superficial exercise with little or no connection to the intended learning outcomes. References 1. Issenberg B, Ringsted C, Østergaard D, Dieckmann P. Setting a Research Agenda for Simulation-Based Healthcare Education. A Synthesis of the Outcome From an Utstein Style Meeting. Sim Healthcare 2011; 6:155–167. 2. Nyström S, Dahlberg J, Hult H. Crossing locations of enacting and observing simulations: Ways of constructing interprofessional learning. Paper to be presented at the Second International ProPEL conference ’Professional Matters: Materialities and Virtualities of Professional Learning’, University of Stirling, UK; 2014, 25-27 June. 3. Schatzki T. The site of the social: A philosophical account of the constitution of social life and change. University Park: Pennsylvania State University Press; 2002. 4. Motola I, Sullivan J, Issenberg S, Devine L, Chung H. Simulation in healthcare education: A best evidence practical guide. AMEE Guide No. 82. Medical Teacher [serial online]. October 1, 2013;35(10):e1511-e1530. 5. Heath C, Hindmarsh J, Luff P. Video in qualitative research: analysing social interaction in everyday life. Los Angeles: SAGE; 2010. 6. Boeije H. A Purposeful Approach to the Constant Comparative Method in the Analysis of Qualitative Interviews. Quality & Quantity 2002; 36:391–409. Disclosures None