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Groundwork

Students’ and Instructors’ Perspectives on Learning and Professional Development in the Context of Interprofessional Simulation

Hadil Elsayeda Department of Education, Communication and Learning, University of Gothenburg, Gothenburg, SwedenCorrespondence[email protected]
ORCID Iconhttps://orcid.org/0000-0001-6857-0526View further author information
ORCID Icon,
Markus Nivalaa Department of Education, Communication and Learning, University of Gothenburg, Gothenburg, SwedenORCID Iconhttps://orcid.org/0000-0002-8360-5392View further author information
ORCID Icon &
Liisa Carlzonb Simulatorcentrum i Väst, Sahlgrenska University Hospital, Gothenburg, SwedenORCID Iconhttps://orcid.org/0000-0002-3925-0491View further author information
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Received 19 Dec 2022, Accepted 07 Jun 2023, Published online: 03 Jul 2023

Abstract

Phenomenon: Simulation-enhanced interprofessional education is a potentially valuable pedagogical approach in health professional education. Simulation-enhanced interprofessional education merits more empirical exploration particularly in terms of experiences from different perspectives. Approach: The study aims to provide a multi-perspective in-depth understanding of students’ engagement in a simulation-based interprofessional learning environment. Ninety students and thirteen facilitators participated. We analyzed data from examination sheets of medical and nursing students in a simulation-enhanced interprofessional education course and from a facilitator survey, using manifest inductive content analysis. The analysis was informed by actor network theory and Schön’s reflection on action model. Findings: Students reflected on their performance in relation to (1) personal attributes, such as systemization skills; (2) other team members, such as communication skills; and (3) the surrounding environment, such as efficient employment of resources. They also reflected on the consequences of their actions and future professional growth. We observed group differences in conceptualizations of performance and knowledge enactment. Facilitators’ and students’ perceptions of performance were mostly aligned. Leadership enactment in the learning environment was problematic for students as well as facilitators. Insights: Students’ engagement in the learning environment helped them develop a prototype of their professional identity and explore potential domains or tools for further learning and professional growth. Features of the learning environment fostered teamwork skills and allowed students to learn from each other, thus improving performance. Our findings have several implications for education, and professional practice, including the need for meticulous planning of learning environments and the importance of more intensive pedagogical efforts for soon-to-be health professionals regarding workplace dynamics and potential conflicts. It is also important to consider that an interactive learning environment can invoke reflection on action not only among students but also among facilitators and that this can contribute to the development of clinical praxis.

1. Introduction

Accelerated change in health systems necessitates innovation in health professional education.Citation1–6 Interprofessional education (IPE) refers to an educational setting where students from two or more professions are educated together, allowing for exchange of information and familiarization with each other’s roles.Citation7 Simulation-based learning can, among other modes of instruction, offer valuable opportunities for IPE, allowing for repeated practice and reducing potential errors.Citation8 Furthermore, it offers a learning environment that is learner-rather than patient-centered, thus allowing health professionals to indulge their learner identities without compromising patient safety.Citation9

Simulation-enhanced interprofessional education (SIPE) has been shown to foster the development of professional identity, to promote skills, and to modify group dynamics.Citation10–12 However, it has been pointed out that several empirical studies lack a sound theoretical framework, thus undermining the value of their findings in contributing to educational development. Moreover, inconsistent with best practice, much of this research lacks clarity in relation to professional roles and learning objectives.Citation13,Citation14

The body of SIPE-related literature has expanded significantly over the past decade.Citation10,Citation11,Citation13,Citation15–17 While this work seems to address many outcomes of the educational experience, such as satisfaction and readiness, it may be argued that the dynamics of the learning environment merit deeper empirical attention, particularly as SIPE environments can be quite complex and may challenge students’ conceptualizations of their professional identities.Citation13,Citation17–20 Moreover, several empirical studies focus on learners rather than instructors.Citation12,Citation15,Citation21 It is useful to keep in mind that SIPE represents an interactive learning experience where faculty also play a meaningful role as facilitators who influence how students experience simulation and can support (or fail to support) learners.Citation22,Citation23 Literature addressing facilitator-related issues in simulation-based learning mostly investigates them independently of their students, and often explores their knowledge of or attitudes toward simulation as an educational approach.Citation24–27 Even when students and facilitators are simultaneously investigated, the focus is mostly directed toward their perceptions of simulation as a tool rather than the learning process itself.Citation28,Citation29

Considering that a mismatch between students’ and facilitators’ perceptions of the learning environment may undermine student development, this study seeks to examine how students engage in a SIPE learning environment and whether their conceptualizations of their own performances coincide with those of their instructors (facilitators). Our aim is to provide a multi-perspective, in-depth understanding of this learning environment. We conceptualize engagement along the three dimensions described by Fredricks and colleagues; behavioral, emotional, and cognitive.Citation30 Behavioral engagement refers to students’ participation in academic and social activities; emotional engagement describes their reactions to peers and faculty; and cognitive engagement is related to how invested students are in developing their knowledge and skills. The study addresses the following questions:

  1. How do medical and nursing students conceptualize their engagement in a SIPE learning environment?

  2. How do facilitators conceptualize the students’ engagement in the SIPE learning environment?

Methods

Background and setting

A Swedish simulation center provides a two-day SIPE course titled Interprofessional Learning (IPL) for final year medical and nursing students (bachelor level). The obligatory course is the first simulation opportunity where both medical and nursing students learn together. The expected learning outcomes are that students will be able to (1) coordinate the resources and competences of the interprofessional team (e.g., assertive leadership and clear communication) to respond to patient needs; and (2) reflect on their respective roles in the team.

IPL is guided by operational algorithms such as ABCDE, CRM and SBAR. ABCDE (Airway, Breathing, Circulation, Disability and Exposure) is a medical approach for effective patient assessment and management.Citation31 CRM (Crisis Resource Management) is a framework of skills (e.g. situation awareness, communication) used to improve clinical practice and enhance patient safety.Citation32 SBAR (Situation, Background, Assessment and Recommendation) is used to promote communication among health personnel.Citation33 The students are provided with relevant literature beforehand to prepare for the course and examination which extend over two days (morning and afternoon).

At the beginning of the first day, all students participate in a 45-minute interactive lecture about leadership and team communication that addresses common practices and challenges for interprofessional work. Moreover, the general working ethic is clarified, including the need for confidentiality. Students are encouraged to contribute to the learning environment and to verbalize their own personal learning objectives for the simulation course.

After the interactive lecture, students are divided into groups that are assigned to various scenarios moderated by facilitators. All facilitators have previously participated in a 3-day course in conducting and facilitating interprofessional teamwork. They are trained to co-facilitate these learning sessions and to promote interprofessional collaboration particularly in relation to desirable patient outcomes. The facilitators work in interprofessional pairs (one physician and one nurse) during the simulation course. Scenarios are designed to target common obstacles in interprofessional teams, such as team communication during handovers, responding to patient concerns (e.g., pain, anxiety, or fear) and bringing them up for team deliberation, collaboratively dealing with workload, ethical aspects such as taking care of a family member (played by a student peer), assertive leadership and speaking up (e.g., some scenarios are designed so that nurses have crucial information for reaching a team decision).

Student groups include on average 3–5 students from each profession (medicine and nursing). The groups work together throughout the 2-day course but have two different pairs of facilitators, i.e., the group works with one facilitator pair during the morning session (2–3 scenarios) then shifts to another pair during the afternoon. The simulation takes place in an authentically equipped simulation room (including resources such as drugs and medical equipment) with a one-way mirror that allows monitoring from the control room, and a full-scale computerized mannequin. A live operator provides the patient’s vocal responses based on a previously prepared script.

Each scenario is preceded by a briefing and followed by a debriefing. The briefing provides the outlines of the scenario with background information about the “patient” and emphasizes the need for group work and effective collaboration. During debriefing, students analyze their actions and give each other feedback. They are prompted by the facilitators to motivate their actions and reflect on them. The facilitators also provide constructive and practical feedback before moving on to the next scenario. The debriefing is conducted according to the 3D (Defusing, Discovering, and Deepening) model of debriefing. Citation22

At the end of the first day, each student is required to fill out an examination sheet (known as a development plan). The plan, which contains five open-ended questions, was designed and developed in collaboration between faculty at the simulation center and at the faculties of medicine and nursing, taking into consideration the intended learning outcomes (see Appendix A for a template of the development plan). On the second day, students discuss their development plans (i.e., examination sheets) with the facilitators in an oral examination with pass/fail grading.

Theoretical framework

The theoretical approach in this study was informed by actor network theory (ANT) and Schön’s model of reflective practice, henceforth the reflection-on-action model (RAM), two approaches that are closely related to practice-oriented theories.Citation34,Citation35

ANT is concerned with the intersections between human and non-human entities to form networks that accomplish social ends. Networks, the meaningful combinations between actors, may be stable or unstable. The more stable and durable a network is, the less visible it becomes as the multiple negotiations and conflicts that went into its formation become masked by its smooth functionality. ANT submits all actors to the same conceptual system with no prior assumptions about agency or power and then traces the micro-relations between them. Agency may thus be extended to objects and even to concepts such as laws and guidelines. ANT also acknowledges the coexistence of multiple realities.Citation35–39 A key concept in ANT is translation, denoting the influence that actors exert on each other, which results in negotiation of relations and configuration of networks.Citation35,Citation40 ANT can provide insights into how issues such as knowledge, power, and identity are negotiated and enacted.Citation35,Citation41,Citation42 ANT analyses are especially useful in educational settings involving new technologies,Citation43 as they can underscore how technologies become incorporated in the learning environment. ANT has recently been highlighted as a useful analytical lens within SIPE environments.Citation18

RAM is an epistemological model emphasizing the relation between reflection and professional development.Citation34 It highlights how meaningful reflection can occur while carrying out a specific action (in action) or after the action is concluded (on action), allowing professionals to externalize tacit knowledge and expand problem-solving skills, thus consolidating their professional identities and developing experience. Reflection on action has been described as a core element in IPE, and operationalization of Schön’s RAM has been advocated as a way of addressing many of the complex issues inherent to these learning environments, including issues of communication and leadership.Citation44 Analysis of participants’ reflections can provide critical evaluation of the pedagogical approaches in place.Citation45,Citation46 SIPE learning environments can benefit from addressing participants’ reflections because they portray the learners’ conceptualizations of the learning process and their static or shifting dispositions thereupon.Citation18,Citation47

Our decision to combine the two theoretical lenses was motivated by a need to account for all the elements involved in such a complex learning environment (e.g., mannequin, equipment, guidelines) as well as a need to understand how participants’ reflections played into the learning experience.

Data collection and participants

We collected data during the academic term autumn 2019. Ninety students and 13 facilitators participated (). The study followed the Swedish research council’s ethical guidelines,Citation48 and collected data were handled and processed according to the General Data Protection Regulation (GDPR).Citation49 However, according to Swedish law, the study did not require clearance from an ethics committee. Two approaches were used for recruiting students; (1) direct invitations extended to students in groups that the research team directly contacted (n = 5 groups), (2) invitations disseminated by faculty to other student groups. Informed consent forms were distributed at the simulation center where students willing to participate could sign them. Signed consents were collected at the end of the second day in the course by the first author who made a list of consenting students and requested copies of their examination sheets from course administrators. The examination sheets were collected on a weekly basis such that data coding could take place in parallel to data collection. Recruitment continued until data saturation was reached.Citation50 During the academic term in question, 234 students attended the course, 90 of whom (38.4%) signed consent forms and were included in the study. Student data comprised the answers they provided in their examination sheets.

Table 1. Description of study participants.

Our preliminary analysis of student data collected during the first three weeks of the autumn term informed the formulation of a facilitator survey which we disseminated to all IPL facilitators (n = 28) who taught during that same academic term (Appendix B). The survey consisted of open-ended questions addressing students’ performance as well as observed intergroup differences. The first author formulated the questions based on recurrent themes from student data, and the third author, who had an extended professional experience with SIPE courses, refined them. We invited the facilitators to join the study via an email that explained the project and provided a link to the survey web page. Facilitators participated by responding anonymously to the survey on a secure university server (the response implied consent). Thirteen facilitators (46%) responded.

Data analysis

We anonymized student data prior to analysis. All data were imported into Nvivo12 to facilitate data management.Citation51 We began the analysis with an initial phase of iterative reading for familiarization with and immersion in the data. We used an inductive manifest content approach for analysis.Citation52,Citation53 The first author coded the data, keeping a codebook documenting the process. Data analysis proceeded in five interrelated stages. The first stage was coding data from students’ examination sheets along the first three weeks of data collection. This provided preliminary themes that informed the formulation of questions for the facilitator survey. The second stage occurred during the interval in which the survey was disseminated to facilitators where more student data were collected, coded and subsequently thematized. The third stage comprised coding of the facilitator survey data. In the fourth stage, we revisited the student data to revise and validate previous interpretations (in light of the preliminary codes generated from facilitator data). Moreover, we held discussions among our research team to explore whether alternative interpretations could be relevant. In the fifth stage, we assimilated the categories, subthemes, and themes into a cohesive whole that reflected the participants’ accounts. We identified five main themes: three in the student data and two in the facilitator data ().

Table 2. Overview of themes, subthemes, and categories.

Results

We present the results in accordance with the research questions including illustrative quotes from participants, who we refer to using assigned numbers. SM denotes a medical student, and SN denotes a nursing student. FD and FN denote physician and nurse facilitators respectively.

How did students conceptualize their engagement in a SIPE learning environment?

We identified three themes in the student data: reflection on performance, reflection on consequences of actions, and reflection on future development.

Reflection on performance

Reflection on performance in relation to self

Students conceptualized their performance as a function of personal attributes. There were group differences in how often students identified strengths/weaknesses (). For example, 37% of medical students considered planning and structure a strength, but only 18% of their nursing peers did. The students evaluated their abilities to handle the patient systematically, referring to the operational algorithms.

Table 3. Key intergroup differences in students’ conceptualizations of their performance.

As a leader, I assigned tasks according to ABCDE and summarized so that everyone was on the same point. (SM76)

I used too few memos/notes before SBAR. ex. when talking to the emergency, it was difficult to remember the exact laboratory values, e.g., CRP, P. glucose, previous diseases/relevant diseases. (SM76)

Here, self-assessment differs according to the benchmark being used for evaluation, where SM76 apparently perceives themselves better at the operationalization of one algorithm than another.

Nursing students brought up stress tolerance and self-confidence more frequently than medical students, both as a strength and as a weakness. Many nursing students associated the ability to work under stress with multitasking skills and professional efficiency.

Can have many balls in the air at the same time, am calm and stress tolerant. (SN56)

Self-confidence was highlighted as an important personal attribute. Medical students often associated self-confidence with the ability to take initiative whereas their nursing colleagues often associated it with the ability to express themselves.

Reflection on performance in relation to team members

Students reflected on intergroup dynamics and emphasized issues related to communication, teamwork, and leadership. We observed some group differences (). Communication skills were considered meaningful for good performance and were described as a strength by almost half the students. Many students described themselves as possessing good co-workership.Footnote1

Can take leadership and have an overall and planning role or be an employee and work practically. (SM3)

Good co-workership; took responsibility over my work tasks and clearly explained when tasks were performed. (SN63)

Various students conceptualized good co-workership differently; some associated it with the ability to change roles within the team, while others referred to being responsive to other team members. The value of responsiveness was more commonly brought up by nursing students (18%, as opposed to only 2% of medical students).

Students repeatedly brought up leadership as a significant aspect of practice. However, it was discussed much more frequently by medical students; among whom 37% referred explicitly to good leadership as a strength, while an additional 18% referred to it implicitly by describing being good at tasks commonly ascribed to leaders, such as assigning responsibilities or defining action plans.

I tried to speak loudly, clearly to the individual concerned. I defined what needed to be done and tried to distribute the workload evenly and according to my colleagues’ areas of knowledge. (SM60)

Occasionally, students reflected on leadership in relation to other management skills, such as being structured or supportive. Two medical students described their exercise of leadership as follows:

Performed good leadership by taking a step back and getting a good overview and was then able to delegate ABCDE to the others in a structured manner. I encouraged initiative-taking–created a good working environment. (SM34)

I have understood that I create a calm and good leadership in the form of good ability to distribute tasks and be clear. (SM42)

Here, SM34 shows a multifaceted understanding of leadership while SM42 reflects on good leadership merely in terms of the ability to assign responsibilities.

Nursing students were less likely to discuss leadership. In contrast, several of them referred to “followership” as a strength. One nursing student referred to the concept of “active followership” and described how it was enacted during simulation:

I also perceive myself as an (active) good follower-if I happened to be without a task, I came up with suggestions/asked the leader to be assigned a task. (SN59)

Another nursing student offered another perspective:

I want to develop leadership at the same time as it felt right to let the medical students take the leadership role, it seemed more natural in my opinion. (SN79)

Here, the notion of medical leadership seems to be an unspoken norm. SN79 simultaneously conveys a wish to develop leadership skills and an inclination to relinquish it to medical colleagues.

Reflection on performance in relation to the environment

The students reflected on their performance in relation to environmental affordances and constraints. Familiarization with the work environment was considered important as students became aware of the need to locate medical supplies during a scenario. They also recognized the importance of being aware of the available resources at a given health facility (e.g., the scope of laboratory investigations) before deciding on a course of action.

CRM point 1. Familiarize myself quickly with the surroundings by looking over the room directly when I step in, simulated 3 times. (SN40)

Notably, the students frequently referred to operational frameworks and algorithms such as CRM and ABCDE as benchmarks for their performance, but they exhibited different levels of reflection in relation to these algorithms. Sometimes the students only stated that they did well with no further reflections on how they did so. Occasionally, they reflected on how they operationalized the algorithm in practice. Curiously, the same student could exhibit both styles in response to different questions. For example, one medical student pointed out a strength as follows:

A strength I think is CRM principle 11, avoid fixation. (SM11)

The same student described a weakness in much more detail:

An example [of weakness] is based on CRM Principle 5: "Distribute tasks." In the leadership role on simulation, it could sometimes be that I did not distribute tasks so well to my medical colleague but often did these myself, such as listening to heart, lungs and the like. The distribution to nursing students went better. (SM11)

There were some group differences in how the environmental affordances were prioritized. Medical students tended to stress the value of using all available resources, including human ones, while nursing students stressed issues such as locating equipment and drugs.

Reflection on consequences of actions

Students described how their actions could affect the general workflow in terms of structure, time management, and results. Some students did not exhibit a concrete understanding of the consequences of their actions and described them in general terms such as “good teamwork.” Others reflected more comprehensively on how their actions could affect the workflow.

Through clarity and a positive climate, the team becomes calm, and they dare, for example, to give suggestions and "speak-up." Re-evaluation is important both for its own structure but also for bringing the whole team together and making sure things are not missed. (SM26)

Here, SM26 exhibits awareness of the multiplicity inherent in the leader role, and how it can affect group dynamics and subsequently the working atmosphere.

Most students lacked concreteness in describing the consequences of their actions for the patient. The terms “patient safety” and “faster help” were repeatedly used without further elaboration. However, some students provided perceptive insights into what their actions meant for the patient psychologically as well as physically. A nursing student paid attention to the next of kin reflecting that:

The patient is treated respectfully and need not worry about his/her relatives. (SN32)

Several students implicitly indicated that in the future they would prioritize the patient’s welfare over other considerations. For example, a medical student, who reported failing to ring for help early during one of the scenarios, mentioned that in the future he would rather “disturb unnecessarily” than risk not calling in time, thus prioritizing the patient’s welfare over other considerations such as shyness or personal ego.

Reflection on future professional growth

Students repeatedly mentioned training as essential for progress. However, many students did not reflect on how this training should proceed nor how its outcomes would be assessed. The workplace was perceived as more realistic, arguably motivating one to “do” things. A medical student described an incident where asking for help was delayed, and reflected that in the future this would be avoided:

I want to get better at asking for help sooner. Rather call [specialist or backup] once too much than too little. I think I will more likely do this when coming out into the clinical where you have more responsibility (compared to a mannequin). (SM68)

Reflection was also perceived as a valuable approach to learning. While some students expressed a rather abstract need to “reflect,” others offered more concrete understandings of how reflection could be actively employed in the learning process, e.g., SM27 who reflected that:

Important to repeat my knowledge and actively think about my strengths and above all weaknesses in order to develop and improve. (SM27)

Here the object of reflection is clearly outlined, and the ultimate result of this reflection is logically incorporated into the process of development.

Students exhibited an appreciation of teamwork for future development. Forty-five and 41% of medical and nursing students, respectively, mentioned colleagues as a source of professional support. Many students perceived one or more personal attribute as a potential obstacle for development, e.g., lack of ambition or difficulty working under stress. Few students identified exogenous obstacles, mostly related to group dynamics at the future workplace such as lack of team cooperation or uneven power relations.

Many students lacked concreteness in visualizing their professional futures especially in relation to anticipated obstacles. Sources of support as well as potential obstacles were listed rather than discussed in many examination sheets. Although question five (in the examination sheet) explicitly requires students to mention the obstacles that could constrain their future development, several students wrote that there were no conceivable hindrances. Moreover, 40% of students (two thirds of whom were medical) ignored that part of the question.

How did facilitators conceptualize students’ engagement in the SIPE learning environment?

Facilitators considered engagement in the learning environment to be beneficial for the development of students from both groups (medical & nursing). We identified two themes from the facilitator data; (1) group dynamics and differences; and (2) student conceptualization of professional self.

Group dynamics

Differences in competences and performance

Facilitators perceived medical students as more systematically adhering to the operational algorithms (e.g., CRM), while they thought nursing students had a better sense of the spirit of CRM in terms of communication skills and responsiveness. Facilitators reasoned that such disparities might be related to various factors including differential prior training, different loci of focus (e.g., nursing students focused more on communication), and traditional norms framing the professional roles of physicians and nurses.

While medical students were considered knowledge oriented, nursing students were seen as more practical. However, facilitators perceived that intergroup interaction helped each group draw upon the strengths of the other. They observed nursing students spoke up more while medical students became more team-oriented.

Generally speaking, nurses are more focused during education on reflection and co-workership. However, I think many medical candidates learn amazingly quickly for just one day. (FN8)

Nurses: flexible and can perform and offer suggestions, more and more dare to speak up. (FN1)

Leadership

Facilitators perceived that medical students were more likely to assume leadership, while most nursing students shied away from it:

Doctors usually take it [leadership] or take it over. Sometimes students have a feeling that you must take the leadership role once and that this is the most important thing. There, good discussions often come up about how one as a leader needs the team and how to reach out to the team. (FN1)

The assumption that a medical student would be the team leader was not based on formal instructions but decided among the students. The questioning of such an assumption provoked some facilitator reflections.

I have been asked the question "Why do you do cases where the doctors should lead?" and was forced to think about it and realized that we have not done so. It is the students who quickly fall into these roles. When the discussion arises, I usually talk with the group about the importance of good teamwork: that it is crazy that we focus so clearly on leadership. In addition, I think that the CRM view of leadership is very unidimensional and flat: group dynamics are considerably more complex than that. (FD3)

Facilitators had different approaches to dealing with the leadership issues. Some of them allowed students to experiment with it over the course of the day until they resolved it themselves, while others encouraged students to take turns at leading. The leadership dilemma was sometimes employed to invite informative discussions on team dynamics as well as to mitigate the hierarchical attitudes that students sometimes fell into. Two of the facilitators had distinct views on this:

They usually talk among themselves before entering the room- set up role distribution. Then it doesn’t always get to be precisely as they thought. But there are usually good conversations about this. (FD2)

I usually argue for the possibility of changing leaders during the scenario and that it does not have to be a doctor. I find this to be positive for both nursing students and medical students and contributes to a less pre-conceived hierarchical order/attitude. (FN3)

Nursing students sometimes questioned the dominancy of medical leadership, but they were more likely to do that on paper (examination sheet) than in person (during debriefing).

Student conceptualization of professional self

Reflections on performance. Several facilitators (5 of 13) pointed out that students tended to focus on their weaknesses rather than strengths. Facilitators perceived that student reflections could be emotional and/or analytical, the latter being more common in the examination sheets than in oral debriefings. One of the facilitators offered an insight into this:

During the examination I think the emotional has settled and it is more analytical. It can sometimes lean towards becoming more theoretical then, because the situation itself is a day old and the emotions are not present in the same way. (FD1)

Reflections on future development

Facilitators perceived student reflections as lacking concreteness and assertiveness in describing their future development. They were more likely to mention the concept of “development” than to describe how it will come about. Potential obstacles to development were often inadequately defined.

Facilitators perceived that the CRM principles, used as a framework for discussing development plans, were sometimes embraced too strictly by students making their plans generic and impersonal. However, there were students who could transcend the textual boundaries of the guidelines and actively apply them to their own experience.

Some very much embrace our concepts (e.g., CRM) and talk based on them, it can tend to be a little impersonal and distanced. But others are better at starting off from the concepts and yet making them their own. (FD1)

Discussion

In this study, engagement in a SIPE learning environment helped students negotiate different aspects of professional knowledge and practice. Group differences were observable where medical and nursing students conceptualized and enacted various elements of collaboration in diverse fashion, possibly due to preconceived notions of professional roles or uneven prior acquaintance with operational algorithms. Facilitators perceived that students’ engagement in the learning environment fostered teamwork skills and allowed student groups to learn from each other, thus improving their performance.

Professional identity in health education

Professional identity refers to the collective understanding, attitude, motivation and experience that one adopts as a way to define being affiliated to a professional community of practice.Citation54–56 In the present study, there were noticeable group differences in how students conceptualized their performances, resonating with empirical findings that indicated differences between medical and nursing students and even professionals in terms of skills and attitudes.Citation57–59

Professional identity in relation to intrinsic factors

Cognitive attributes

Systemization skills (i.e., the ability to systematically work through a clinical scenario according to clinical guidelines) were generally reflected upon as individual attributes. More medical than nursing students expressed confidence in their systemization abilities, and facilitators harbored a comparable perception. This finding resonates with prior reports of differences between physicians and nurses in documentation and execution of clinical protocols.Citation57,Citation60 While systemization skills were often referred to as intrinsic abilities, their assessment occurred within the boundaries of the operational algorithms used for training, e.g. ABCDE. Operational guidelines can influence human activities thus acquiring a form of agency.Citation42 Students tended to configure their practice around the constellation of principles offered or imposed by the guidelines. In ANT terms, the algorithms acquired an agency that translated knowledge into practice. During the 2-day IPL course, actions were problematized and (re)configured to strike a balance between theoretical knowledge and prior conceptualizations of professional roles on the one hand and collaborative practice and arising conflicts on the other.

Facilitators noted that medical students had probably had more training in ABCDE than their nursing colleagues. This implies that the students had different prior conceptualizations of clinical praxis, resulting in a differential enactment of knowledge and consequently in divergent conceptualizations of strengths and weaknesses.

Affective attributes

Self-confidence and stress tolerance have been problematized among nursing students and practitioners across settings and contexts.Citation61–64 Medical trainees have also struggled with these issues.Citation65–67 In our study, it was mostly nursing students who discussed performance in relation to self-confidence and stress tolerance. These findings are not necessarily at odds with previous literature. It is conceivable that nursing students chose to externalize the affective aspect of their performance more than their medical peers. This may have been a function of their educational background, where nursing curricula have traditionally emphasized the contact with self more than medical ones.Citation68 Another potential explanation is the differential gender composition of the two groups, where almost 80% of nursing students were females. Female health students and professionals are more likely to experience emotional exhaustion and reduced self-confidence.Citation61,Citation69

A third potential interpretation is the differential conceptualization of one domain of professional performance (systemization skills) influencing the assessment of another domain (self-confidence). Nursing students, perceiving themselves as less systematic, may have developed a conceptualization of a less competent professional self, incurring an emotional burden. That burden was then externalized in discussions of self-confidence and stress tolerance, whether as obstructive factors preventing students from realizing their full professional potential or as compensatory strengths that allowed students to mitigate other weaknesses.

Student conceptualizations vs. facilitator conceptualizations

Facilitators’ perceptions of students’ strengths and weaknesses were largely aligned with the students’ own perceptions. However, facilitators indicated that students tended to focus on their weaknesses rather than their strengths. From an ANT perspective, the focus on weaknesses can be explained by the invisibility element within networks.Citation36 Individual elements of smoothly functioning networks may be masked by the functionality of the network. A discerning eye is needed to break down a network into the basic energies that went into its construction. The more experienced facilitators would be in a better position to appraise strengths and weaknesses, whereas students would be more likely to see the nonfunctioning elements of the network, in this case their weaknesses.

Professional identity in relation to extrinsic factors

How the mannequin and the operational algorithms featured in teamwork

The mannequin and the operational algorithms were meaningful both for team collaboration and self-assessment. Hopwood and colleagues pointed out that the affordances of the mannequin in a SIPE environment were instrumental in knowledge enactment.Citation18 Following their line of reasoning, we point out that although the mannequin is given a voice by the operator in the control room, it still cannot display all the physical signs that a real patient would. For example, a real patient may develop cyanosis,Footnote2 while the mannequin cannot. In this context, students working around the mannequin would need to be extra articulate in reporting vital signs (e.g., breathing, circulation), which brings communication and collaboration to the forefront of clinical management. In a pedagogical sense, the communication issue becomes more salient within SIPE than within a traditional internship setting. The latter is by default patient-centered, and likely to become more so during an emergency, which may result in novices missing subtle communication cues that were fashioned within an ongoing community of practice over time. In their reflections, students almost always referred to one of the algorithms and how it was operationalized, suggesting that both the mannequin and the algorithms mediated the translation of theoretical to practical knowledge.

Group differences

Although both student groups (medical and nursing) emphasized the importance of teamwork and communication skills, facilitators perceived that nursing students exhibited superior communication and collaboration skills. Previous studies suggest that nurses are better at, and more appreciative of, collaborative work than physicians.Citation59,Citation70 These differences may reflect discrepancies in learning traditions and professional framing between the two professions and do not necessarily suggest discrepancies in students’ engagement in the learning environment. Earlier nursing textbooks stressed the nurse’s obligation to be alert and responsive while physician textbooks focused on subject matter emphasizing the cognitive aspect of the profession.Citation68 In contemporary contexts, medical education often takes place in highly competitive environments that emphasize independence while nursing education promptly introduces learners to teamwork.Citation71 It is possible that today’s health care students, consciously or otherwise, still ascribe to the traditional conceptualizations of their respective professional roles. While contemporary nurses view their professional roles as multifaceted, they continue to hold attributes such as compassion, and practical readiness as valuable codes of practice.Citation72,Citation73 On the other hand, physicians associate their professional role with decision-making and leadership.Citation74,Citation75

The issue of collaboration may have been differentially conceptualized (and enacted) among students in this study. The observed group disparities may be attributed to the still immature student attempts at adopting their perceived professional roles. The implications of professional norms for professional identity formation and development have been pointed out by Nicolini and Roe,Citation76 who refer to a profession’s “authority” that lays down the boundaries of what is expected within a given occupation.

In the present study; discourses, students, and clinical scenarios became a network of interacting energies,Citation77 whereby the inclusion/exclusion of different aspects of knowledge and practice were negotiated ending up in the adoption of the attitudes perceived as best fitting one’s designated role in the team. Such an understanding resonates with Billett’s notion of dispositional knowledge and how student values shape how they engage in practices.Citation47

Leadership

Leadership was repeatedly problematized by students and facilitators. Medical students tended to assume leadership while their nursing peers tended to avoid it. Prior studies have highlighted the reluctance of nursing students and nurses to assume leadership.Citation78,Citation79 This attitude may be linked to discourse heritages that emphasized the superiority of physician judgment and the nurse’s moral duty to be guided by it.Citation68 However, the conceptualization of leadership within health care has been gradually changing in conjunction with growing appreciation of interprofessional collaboration.Citation80–82 Thus, it may be appropriate to offer students more pedagogical support in understanding and practicing the leader role.

In our study, many students lacked a cohesive understanding of leadership. The issue was even problematic for facilitators. Students’ discussions and experiences of leadership differed in various groups. According to ANT, networks develop through ongoing interactions between persons, artifacts or ideas.Citation39 The current, rather brief, SIPE was the first educational encounter between the medical and nursing students who had not had a chance to develop an interpersonal repertoire, a meaningful component of collaborative networks.Citation39 It is conceivable that peer communications varied considerably across groups. In ANT terms, the leadership issue was experienced and negotiated in various ways because of the multiple realities experienced by members in different groups. Interestingly, the dilemmas created by students’ negotiations of leadership influenced the facilitators’ conceptualization of the issue. Considering that students and facilitators are soon to be members of the same community of clinical practice,Citation83 this can be meaningful for future workplace dynamics.

The affordances and limitations of the environment

The mannequin was central to the learning process. The tangibility of the mannequin and the range of responses it offered, made knowledge more concrete where actions and consequences could be more distinctly linked together invoking modifications in beliefs and performances. Revision of prior, less informed beliefs is a part of the process of professional identity development.Citation84

Although both student groups acknowledged the meaningfulness of the surrounding environment, nursing students were more focused on material elements (e.g., equipment,) that were necessary for practical readiness, perceived as an element of professional competence.Citation72 This resonates with the facilitators’ perception of nurses as practice-oriented. By contrast, medical students, who were more comfortable with task organization and leadership, focused on how best to manage human resources.

Students’ reflections on future development

Although reflections on future progress tended to be abstract, they still indicated how students resolved, at least partially, the conflicts they faced and how they intended to transfer the learning experience to other settings.Citation34,Citation85,Citation86 The abstractedness of their future plans may have been due to a future vision constrained by the operational algorithms used in training, or a lack of practical experience that made them unable or reluctant to problematize issues in a future work place.

Nursing students were more likely to reflect on obstacles for development, possibly due to being practically oriented and thus more capable of anticipating potential areas of dysfunction in their prospective workplaces. The lack of conceptualization of future obstacles may be cause for concern regarding future clinical practice.Citation84 Increasing numbers of health care professionals suffer from burnout related to clinical practice.Citation87–90 Inadequate educational support can be a potential trigger for burnout syndrome.Citation89 Thus, it is relevant to stress the importance of more intensive pedagogical efforts for soon-to-be health professionals to clarify potential conflicts.

Strengths and limitations

This study builds on and contributes to the body of pedagogical and health literature. It responds to calls for more rigorous SIPE research within health professional education,Citation13 and focuses on the learning environment rather than learners’ satisfaction or readiness which have previously been common targets of empirical investigation.Citation11,Citation21 Moreover, we offer a multi-perspective analysis of the learning environment based on student and instructor experiences from both the medical and nursing professions.

The relatively large student sample with variation in age, gender, and educational background enriched the data, as it provided what can be seen as a maximum variation sample.Citation91,Citation92 The facilitator sample also offered considerable variation in terms of professional backgrounds and teaching experience. This study also exemplifies the benefits of combining two theoretical approaches–ANT and RAM—such that their individual strengths could be exploited. A methodological strength is that student data were collected from examination sheets written after the first day of simulation. The timing of answering the questions was close enough to the SIPE experience to make it still cognitively and emotionally relevant, but distant enough to allow for a more analytical stance in reflection. Facilitators indicated that students offered more in-depth insights in their examination sheets than during debriefings. However, facilitators also pointed out that some students had better verbal than written faculties, and these students may not be adequately represented in the current findings.

A potential limitation is that the data were collected in the context of an examination and may have been influenced by the psycho-emotional stress associated with this experience and/or by social desirability.Citation93,Citation94 Nonetheless, it is important to point out that the examination in question was a pass/fail assessment and that obtaining a pass degree was contingent on the student’s reflections being objective rather than on scientific knowledge or clinical performance. This would have contributed to a less stressful atmosphere and a more transparent self-assessment. Another limitation is that the written examination was self-administered and structured, eliminating any opportunity for more in-depth probing by the researchers. While this increased the comparability of results, it may have limited both the scope of the study and the depth of interpretation.Citation52,Citation92 However, it should be observed that the combination of findings from student and facilitator data produced a relatively more comprehensive understanding of the learning environment. A final limitation may be that we did not account for the facilitators’ prior clinical experience in terms of specialty. For example, a facilitator who had more experience with emergency medicine might have had different conceptualizations than one who had mostly worked in internal medicine.

Conclusion and implications

In our study, students apparently identified with different roles and responsibilities within the learning environment. It can be reasoned that a network was formed,Footnote3 where the eventual learning was a function of: (1) the mannequin, which embodied the consequences of actions; (2) team members who contributed to the management plan; (3) materials in the learning environment (e.g., equipment) that allowed/constrained actions; (4) preexisting but also continuously developing conceptualizations of professional roles; (5) guidelines framing practice, such as CRM, which outlined how practice should be arranged; and (6) the pedagogical discourse (debriefings) where all of the above could be processed forming a new set of conceptualizations that would in turn be carried over to the next scenario. Here, the notion of fluidity in ANT,Citation40 where networks are dynamic rather than static configurations, can be useful in understanding how students within the rather brief duration of the course negotiated their perceptions and practices such that they came to learn from each other and improve their collective performance as noted by the facilitators. In this context, the actual time duration may not have been as meaningful for learning as the diversified experiences packed into it.

The findings of this study have implications for education, professional practice and future research. For example, it would be appropriate to make sure that students’ understanding of and familiarization with operational algorithms are aligned prior to an interprofessional course. It would also be beneficial to design structured pedagogical approaches to frequently problematic issues such as leadership.

Practice-wise, the present findings suggest that issues raised by students occasionally invoke facilitator reflection on action, which may culminate in modifications of facilitator attitudes or professional practices (i.e., facilitators also learn). Empirically, there is a need for further investigation of SIPE learning environments preferably in a more systematic fashion and using combinations of quantitative and qualitative approaches not only to explore the development of professional identity within the learning environment, but also to understand how this identity is transferred and perpetuated post-training.

Acknowledgements

The authors express their deep gratitude to all the students and facilitators who took the time to participate in this study and hope that they find the current findings meaningful.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes

1 In Swedish the term is “medarbetarskap” and is used to express the involvement in teamwork in a cooperative, productive, and responsible manner.

2 A bluish discoloration of the skin due to poor oxygenation of the blood.

3 More accurately, an umbrella network composed of several interacting and overlapping smaller networks.

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Appendix A

Student development plan template (translated from Swedish)

  1. Based on the CRM principles and feedback you have received, what are your main strengths in an interprofessional team that lead to effective and patient-safe care of an acutely ill patient? Give at least two concrete examples from day 1 that highlight your strengths.

  2. What impact do these strengths have on the others in the team and on the patient?

  3. Based on the CRM principles and feedback you received, what are your weaknesses? Give at least one example from day 1 that highlights your weaknesses:

  4. What are the consequences of these weaknesses for the others in the team and for the patient?

  5. Development goals: After simulation day 1, self-reflection and the feedback you received; what behaviors of yourself, strengths and weaknesses do you want to continue to use or develop? How can you do that? What/who can you get help from and are there any obstacles to your development?

Appendix B

Facilitator survey (translated from Swedish)

  1. What characterizes students’ way of describing their strengths and weaknesses in debriefing and examination? Are there any differences between medical and nursing students? If so, what?

  2. What strengths and weaknesses from CRM do you think you often see among medical and nursing students in simulations? How do you notice it? Do you have any thoughts on what it depends on?

  3. What characterizes the way students describe their future development plan?

  4. During the examination, some students describe other things in the oral part compared to what they have written in the development plans. How often have you experienced it? What has this been about? What do you think this depends on?

  5. Based on your experience with the students who do not have the same educational background, have you noticed that there are some gaps in their competence/education/understanding? What can you contribute to deal with such gaps?

  6. How do you feel that students solve the leadership issue in the interprofessional teams during the simulation? How do you as a facilitator usually help in this respect?

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