A Conceptual Framework for Simulation in Healthcare Education® © 2014

Please select each number in sequence to obtain the information of each education theory making up the conceptual framework. If the graphic does not open, click on the numbers underneath the graphic for this information.
Conceptual Framework for Simulation in Healthcare Education ® 2014 ©. Modified and transformed from the Australian Qualifications Framework (AQF) spinning wheel mechanism. Permission granted for use under Creative Commons Attribution 3.0 Australia licence, Commonwealth of Australia ©. Governance, Quality & Access Branch, Higher Education Group, Australian Government Department of Education and Training. Cited: http://www.aqf.edu.au/aqf-levels.

1: Adult Learning Theory

Theory

Andragogy

Theorist(s) to consider Plato
Alexander Kapp
Eugen Rosenstock-Huessy
John Dewey
Eduard Lindeman
Malcolm Knowles

Rationale

Since the early identification that adults learn from a different perspective than children this theory has been widely applied. While there have been many variations offered, the central tenant remains.  

Initial work by Dewey (1916; 1933) and Lindeman (1926; 1956; 1987) based their work on both being an adult learner and being a teacher of adults. Some of the key assumptions about adult learners include:

  • They are motivated to learn when they experience needs and interests
  • Adults’ orientation to learning is life-centered
  • Experience is the richest source for adult’s learning
  • They have a deep need to be self-directing
  • Andragogy is based upon Lindeman's adult learning theories

From the works of Knowles (1980; 1984; 1990) who is the more contemporary theorist, the underlying premise of andragogy is based on a range of quite specific assumptions about how adult learners learn.  These are quite different from the assumptions about how children learn – on which the theory of pedagogy is premised (not relevant to this framework).

While there may be debate around the definitions and applications of these terms there remains a consensus that the adult learning principles of andragogy remain a sound education theory. 

Knowles characteristics of adult learners are identified as:

  • Self-concept:  As a person matures his self-concept moves from one of being a dependent personality toward one of being a self-directed human being;
  • Experience:  As a person matures he accumulates a growing reservoir of experience that becomes an increasing resource for learning;
  • Readiness to learn:  As a person matures his readiness to learn becomes oriented increasingly to the developmental tasks of his social roles;
  • Orientation to learning:  As a person matures his time perspective of learning changes from one of postponed application of knowledge to immediacy of application, and accordingly his orientation toward learning shifts from one of subject-centeredness to one of problem centeredness;
  • Motivation to learn:  As a person matures the motivation to learn is internal.  
Source:  Accessed 24.10.2014
 

Knowles (1980; 1984; 1990) also identifies four principles that are applied to adult learning:

  • Adults need to be involved in the planning and evaluation of their instruction.
  • Experience (including mistakes) provides the basis for learning activities.
  • Adults are most interested in learning subjects that have immediate relevance to their job or personal life.
  • Adult learning is problem-centered rather than content-oriented. (Kearsley, 2010)  

Source:  Accessed 24.10.2014

It can be argued that the majority of learners who will be exposed to the use of simulation as a teaching, learning and assessment method will be adults who will demonstrate these characteristics and principles.

Therefore there is an expectation at least that these leaners needs and outcomes will be addressed by the andragogy model.

It can be argued that the Knowles principles resinate with simulation and thus provide the adult learner a relevant process and a spectrum of applications that will coincide with and be relevant to their learning requirements.

Considerations

When developing a curriculum, course, tutorial, workshop, scenario, learning objectives/outcomes where simulation will be embedded and integral to the educational / assessment process:  Consider:

  • What foundational andragogy factors are important to review and consider (this links to other education theories)?
  • How will andragogy principles and adult learning strategies / activities guide these developments?
  • Where will adult learning be of benefit?
  • When will adult learning be of benefit?

Consider andragogy – adult learning - and where it intersects with:

  • The curriculum;
  • The teacher / instructor / facilitator / technician;
  • The individual learner’s learning style and characteristics (see conceptual framework theory);
  • Groups of learners;
  • A learner’s work experience;
  • A learner’s professional development profile;
  • Heutagogy (see conceptual framework theory);
  • Tacit knowledge (see conceptual framework theory);
  • Education taxonomies and simulation;
  • Identified learning objectives and outcomes;
  • Situated learning;
  • Contextual learning;
  • Scaffolded learning;
  • Experiential learning (see conceptual framework theory);
  • Critical thinking (see conceptual framework theory);
  • Clinical reasoning;
  • Clinical judgment;
  • Feedback and debriefing (see conceptual framework theory);
  • Reflective learning (see conceptual framework theory);
  • Competency attainment (see conceptual framework theory);
  • Self-efficacy (see conceptual framework theory);
  • Expert practice (see conceptual framework theory);
  • Complexity (in learning and environment);
  • Authenticity (in learning and environment);
  • Fidelity (in learning and environment);
  • Resources (educational, human, technical, infrastructure).

Note: New learners commencing undergraduate or graduate studies on their progression to becoming healthcare professionals may require modification in the how they receive their education initially.

However many will already have had secondary school / college exposure to self-directed learning / e-learning / researching material / working alone / in teams / identifying their own needs based on their perceptions of what is expected.

2: Self-determined Learning

Theory

Heutagogy

Theorist(s) to consider Stewart Hase and Chris Kenyon

Rationale

The study of self-determined learning.  

The concept of Heutagogy offers a number of principles and practices that could be seen as a response to current identified education issues, limitations, changes and challenges especially from a changing work environment and from emerging technologies perspectives.  

While Heutagogy has strong educational links to Andragogy in that it takes on board the assumptions and principles of adult learning (self-directed) then applies a holistic approach to developing learner capacity and capabilities (self-determined).  

As in an Andragogical approach, in Heutagogy while the educator facilitates the learning process by providing guidance and resources, the educator then fully relinquishes ownership of the learning path and process to the learner, who negotiates learning and determines what will be learned and how it will be learned.  

With Heutagogy, learning is seen as a learner-led active and proactive process, with learners being the lead player in their own learning, centred on tacit knowledge and personal experiences.  The purpose that underlines this approach is a need to move past the gaining of knowledge and skills as a learning experience – and for the learner to identify what is relevant and required for them.  

According to Hase and Kenyon (2001) Heutagogy: ‘Takes account of intuition and concepts such as ‘double loop learning’ that are not linear and not necessarily planned. It may well be that a person does not identify a learning need at all but identifies the potential to learn from a novel experience as a matter of course and recognises that opportunity to reflect on what has happened and see how it challenges, disconfirms or supports existing values and assumptions’  

Hase and Kenyon (2001) also indicated that Heutagogy; 'includes aspects of capability, action learning processes such as reflection, environmental scanning as understood in Systems Theory, and valuing experience and interaction with others. It goes beyond problem solving by enabling proactivity.’

Source:  Accessed 15.11.2014

A Heutagogical learning environment facilitates both the development of capacity and capability in learners, and development of learner competencies with the goal of learners being work ready and work safe and prepared for the complexities of the contemporary workplace.

Source:  Access 15.11.2014

Thus this theory resonates strongly with Constructivism, Andragogy, simulation, learning with technology and with the other theories in this framework.

Considerations

When developing a curriculum, course, tutorial, workshop, scenario, learning objectives/outcomes where simulation will be embedded and integral to the educational / assessment process: Consider:

  • What Heutagogical factors are important to review and consider (this links to other education theories)?
  • How will Heutagogical principles and strategies / activities guide these developments?
  • Where will self-determined learning be of benefit?
  • When will self-determined learning be of benefit?

Consider Heutagogy – self-determined learning - and where it intersects with:

  • The curriculum;
  • The teacher / instructor / facilitator / technician;
  • The individual learner’s learning style and characteristics (see conceptual framework theory);
  • Groups of learners;
  • A learner’s work experience;
  • A learner’s professional development profile;
  • Andragogy (see conceptual framework theory);
  • Tacit knowledge (see conceptual framework theory);
  • Education taxonomies and simulation;
  • Identified learning objectives and outcomes;
  • Situated learning;
  • Contextual learning;
  • Scaffolded learning;
  • Experiential learning (see conceptual framework theory);
  • Critical thinking (see conceptual framework theory);
  • Clinical reasoning;
  • Clinical judgment;
  • Feedback and debriefing (see conceptual framework theory);
  • Reflective learning (see conceptual framework theory);
  • Competency attainment (see conceptual framework theory);
  • Self-efficacy (see conceptual framework theory);
  • Expert practice (see conceptual framework theory);
  • Complexity (in learning and environment);
  • Authenticity (in learning and environment);
  • Fidelity (in learning and environment);
  • Resources (educational, human, technical, infrastructure).

Note: New learners commencing undergraduate or graduate studies on their progression to becoming healthcare professionals may require modification in the how they both receive and perceive their education requirements initially.

However many will already have had secondary school / college exposure to self-directed learning / e-learning / researching material / working alone / in teams / identifying their own needs based on their perceptions of what is expected.

Thus they may be ideal candidates to guide towards a Heutagogical approach once certain curriculum factors have been addressed.

3: Tacit Knowledge

Theory

Tacit Knowledge

Theorist(s) to consider Michael Polanyi
Richard B. Gasaway

Rationale

The concept of Tacit Knowledge - also known as informal knowledge - was developed by Michael Polanyi  (2006)

Every individual will bring to a new learning situation their previous educational, social and cultural knowledge, experiences, beliefs, views, prejudices, perceptions and expectations. They also bring those accumulated unconscious and conscious environmental experiences gathered and stored on a daily basis that help develop and guide an individual’s life. 

These stored memories and learnings have the capacity in various ways to impact either positively or negatively on a learning experience. They can be of benefit in acquiring new knowledge and expertise as they facilitate new learning. However they can also impede new learning so it is important at least to acknowledge this phenomenon as a moderating factor in designing and delivering education experiences.

On the Business Directory website there is a confirming definition that would support this. Tacit knowledge is seen as, ’the unwritten, unspoken, and hidden vast storehouse of knowledge held by practically every normal human being, based on his or her emotions, experiences, insights, intuition, observations and internalized information’.

Source:  Accessed: 14.11.2014

Gasaway (2013) identifies tacit knowledge as; ‘the collection of life’s experiences, education and training that reside outside conscious awareness.  It’s the knowledge one possess that helps guide intuition, a vital component to making high-stress, high-consequence, split second decisions’.

Gasaway (2013) notes that; ‘the only way to develop tacit knowledge is exposure to new experiences (i.e., learning) and repetitive exposure to existing experiences (i.e., practice). Novices [learners] can advance the development of tacit knowledge by training in realistic and repetitive scenarios and by exposure to lessons of past successes and failures … the more realistic the experience is made for the novice [the learner], the more likely the experience will seat into unconscious knowledge.’

This notion of engaging current tacit knowledge and building on it through an education experience resinates well with simulation. 

When designed and delivered effectively simulation can provide the type of teaching and learning experience which either exposes the learner to a new experience – and the building of further tacit knowledge – or adds to previous experiences and tacit knowledge.

Thus, according to Gasaway (2013); ‘the tacit knowledge gained from simulations can add to both the conscious and unconscious experience healthcare learners have when engaging future patients’. Source:   Gasaway, R. (2013) Tacit Knowledge and Situational Awareness, Situation Awareness Matters, Website accessed: July 20 2013 @ 1700.

Considerations

Remember every person will have differing Tacit Knowledge. New learners (students) will have different incoming Tacit Knowledge to that of learners who have experience and expertise. Being first aware of this factor and catering for it is an important activity. It is strategic to explore this with learners to gain an overview of individual and group Tacit Knowledge.

 When developing a curriculum, course, tutorial, workshop, scenario, learning objectives/outcomes where simulation will be embedded and integral to the educational / assessment process: Consider:

  • What Tacit Knowledge factors are important to review and consider (this links to other education theories)?
  • How will Tacit Knowledge principles and strategies / activities guide these developments?
  • Where will Tacit Knowledge learning be of benefit?
  • When will Tacit Knowledge learning be of benefit?
    Consider Tacit Knowledge and where it intersects with:
  • The curriculum;
  • The teacher / instructor / facilitator / technician;
  • The individual learner’s learning style and characteristics (see conceptual framework theory);
  • Groups of learners;
  • A learner’s life and work experience;
  • A learner’s professional development profile;
  • Andragogy (see conceptual framework theory);
  • Education taxonomies and simulation;
  • Identified learning objectives and outcomes;
  • Situated learning;
  • Contextual learning;
  • Scaffolded learning;
  • Experiential learning (see conceptual framework theory);
  • Critical thinking (see conceptual framework theory);
  • Clinical reasoning;
  • Clinical judgment;
  • Feedback and debriefing (see conceptual framework theory);
  • Reflective learning (see conceptual framework theory);
  • Competency attainment (see conceptual framework theory);
  • Self-efficacy (see conceptual framework theory);
  • Expert practice (see conceptual framework theory);
  • Complexity (in learning and environment);
  • Authenticity (in learning and environment);
  • Fidelity (in learning and environment);
  • Resources (educational, human, technical, infrastructure).

4: Learning Styles / Characteristics / Preferences

Theory

Learning Styles

Theorist(s) to consider Kolb’s Learning Styles Inventory (LSI)
Honey and Mumford’s Learning Styles Questionnaire (LSQ)
Fleming’s Visual Auditory Kinesthetic (VAK) model.

Rationale

According to Clark (2014), ‘a learning style is a student's consistent way of responding to and using stimuli in the context of learning.’

Source:

Keefe (1979) defines learning styles as the “composite of characteristic cognitive, affective, and physiological factors that serve as relatively stable indicators of how a learner perceives, interacts with, and responds to the learning environment.” Stewart and Felicetti (1992) define learning styles as those “educational conditions under which a student is most likely to learn.”

This indicates that learning styles are not really concerned with what learners learn, but rather how they prefer to learn.

Thus it is important that teaching, learning and training programs reflect the learning styles, characteristics and preferences of individuals in order for them to be effective.

Kolb

While there are scores of learning theories and models in the education literature the learning style theory and model that appears to dominate the simulation literature - from a reference perspective – but significantly less from a research perspective – is the work of Kolb.

According to Kolb (1984) effective learning involves the learner;

  • Feeling a concrete experience;
  • Undertaking reflective observation (watching the experience);
  • Generating abstract conceptualisation (thinking about the experience); and,
  • Undertaking active experimentation (generating activity – doing).

Kolb (1984) also identifies four types of learners;

  • Divergers, who feel and watch the learning experience (tend to reflect and brainstorm);
  • Assimilators, who think and watch the learning experience (tend to apply inductive reasoning, generate ideas, develop concepts);
  • Convergers, who think and get actively involved in the learning experience (learning by doing) (tend to problem solve, be decision making and utilise practical skills); and,
  • Accommodators, who feel and carry out the learning experience (tend to use experience, carry out tasks, are adaptive and have intuitive skills).

This is demonstrated in the following graphic – based on the two intersecting cognition planes Kolb identified: the perception and processing continuums.

Learning Styles / Characteristics / Preferences

Source:

Note: This graphic is also used to describe experiential learning theory. This learning styles inventory model is a variation on the experiential learning theory which will be discussed separately.

Honey and Mumford

Kolb has dominated the learning theory landscape and has inspired many other theorists. Honey and Mumford draw on Kolb’s model but they differ in their inventory approach. While Kolb’s inventory asked people directly how they learn, Honey and Mumford inventory seeks out general behavioural tendencies. They believed most people didn’t really think about how they learn and even move in and out of different learning styles - depending on the situation.

As a result, while their model was essentially the same as Kolb's model, Honey and Mumford introduced some differences in terminology and meaning. They replaced the terms with their own terms:

  • “reflector” for divergers (reflective observation);
  • “theorist” for assimilators (abstract conceptualization);
  • “pragmatist” for convergers (concrete experience);
  • “activist” for accommodators (active experimentation).

Honey and Mumford's learning cycle also slightly differs from Kolb's. Honey and Mumford identified learners as having an experience, reflecting on it, drawing their own conclusions (theorising) and then putting theory into practice. See graphic.

Learning Styles / Characteristics / Preferences

Source:

Honey and Mumford also acknowledged that learners could continually move around the cycle, step in any part of the cycle, and then step out when they considered they had achieved success by learning the theory / content and the task or skill.

When shown these models many healthcare professionals can identify their own learning preferences when consciously asked about them. Indeed this is a simple and useful exercise as it helps the teacher / facilitator design / deliver / pace an educational activity to more effectively capture most learning styles.

Fleming

Fleming’s Visual Auditory Kinesthetic (VAK) model too resinates well with the learning characteristics of healthcare workers. With this model, most people possess a dominant or preferred learning style; however some people have a mixed and evenly balanced blend of the three styles:

  • Visual learners
  • Auditory learners
  • Kinaesthetic learners

Note: The preferences of these learners are too extensive to list in the framework. On the James Cook University (JCU) website under JCU Workplace Educators Resource Package there is an extensive list of excellent descriptors of what these types of learners tend to do. I recommend visiting this link and reading over these:

Link:

There is similar material on VAK to be reviewed at:

Source:

Note: When you visit the website you can do your own assessment of your own learning style according to the VAK model and reflect on your learning style. Links to the assessments are provided.

In conclusion whether it is Kolb, Honey and Mumford, Fleming or any other learning styles / preferences theorist you are considering to help guide you develop and deliver a simulation, in a simulation activity it then becomes important how might these differing learning preferences be accommodated and addressed so that learning outcomes are achieved by all.

Considerations

When developing a curriculum, course, tutorial, workshop, scenario, learning objectives/outcomes where simulation will be embedded and integral to the educational / assessment process:  Consider:

  • What Learning Style factors are important to review and consider (this links to other education theories)?
  • How will Learning Style principles and strategies / activities guide these developments?
  • Where will knowledge of Learning Styles be of benefit?
  • When will addressing Learning Styles be of benefit?

Consider Learning Styles,  Characteristics and Preferences and where they intersect with:

  • The curriculum;
  • The teacher / instructor / facilitator / technician;
  • The individual learner;
  • Groups of learners;
  • A learner’s work experience;
  • A learner’s professional development profile;
  • Andragogy (see conceptual framework theory);
  • Tacit knowledge (see conceptual framework theory);
  • Education taxonomies and simulation;
  • Identified learning objectives and outcomes;
  • Situated learning;
  • Contextual learning;
  • Scaffolded learning;
  • Experiential learning (see conceptual framework theory);
  • Critical thinking (see conceptual framework theory);
  • Clinical reasoning;
  • Clinical judgment;
  • Feedback and debriefing (see conceptual framework theory);
  • Reflective learning (see conceptual framework theory);
  • Competency attainment (see conceptual framework theory);
  • Self-efficacy (see conceptual framework theory);
  • Expert practice (see conceptual framework theory);
  • Complexity (in learning and environment);
  • Authenticity (in learning and environment);
  • Fidelity (in learning and environment);
  • Resources (educational, human, technical, infrastructure).

5: Experiential Learning

Theory

Experiential Learning

Theorist(s) to consider John Dewey
Kurt Lewin
Karl Rogers
Jean Piaget
David Kolb
John Seely Brown, Allan Collins and Paul Duguid

Rationale

The educational concept of experiential learning is a well-established approach in adult education theory. There is frequent reference to Experiential Learning in mainstream education and healthcare simulation education literature. A search of the simulation literature will provide many references referring to Experiential Learning. This indicates at least that more and more people are identifying / demonstrating the need for an education theory underpinning their activities. However there are far less publications – in simulation education – where research has demonstrated how that recognition has been then applied and measured in terms of outcomes.

Experiential Learning as an education theory does strongly resinate with simulation as a learning and teaching process - due to the very essence of most simulation-based learning being experiential in design and intent. But Experiential Learning is not just about the exposure to and the doing of an activity – it is also about how the participant reviews, processes, reflects and demonstrates an outcome as a result. It is not just the experience itself – although that provides the relevant context and trigger(s) for the learner to acquire / refresh and apply knowledge, feelings, attitudes and skills.

Importantly it is Experiential Learning that addresses the needs and wants of the learner - and this requires: the learner’s personal involvement, it is self-initiated; it is evaluated by the learner as to its relevance and that it has all-encompassing effects on the learner. Indeed Experiential Learning is providing a platform for constructivist learning to occur.

There are any number of theorists who describe Experiential Learning from their different perspectives and their focus. It is not the intention in this framework to exposé them all but rather to raise to a conscious level the need to consider the most appropriate one(s) that suit your needs. Those noted here are the most reviewed and who have most impacted on the contemporary theory mentioned here.

While the founders of this approach include John Dewey, Kurt Lewin Karl Rogers, Jean Piaget – whose works have all influenced David Kolb - it is Kolb’s Experiential Learning Theory and four-stage model – based on Lewin’s graphic - that dominates current approaches to experiential learning, and one that lends itself to healthcare simulation education.

Kolb

Kolb's Experiential Learning Theory and learning styles model

Kolb (1984) saw learning – the creating of knowledge, skill and attitudes – occurred as a result of an exposure to an experience and the transforming of that experience into the learning outcome. He also identified that learning is based on how learners prefer to learn.

Kolb’s Experiential Learning Theory establishes four distinct learning styles -or preferences - which are based on a four-stage learning cycle (courtesy of Lewin). Kolb's model offers both a way to understand individual learning styles, and also an explanation of a cycle of experiential learning that applies to all learners.

These graphics demonstrate the Experiential Learning Cycle.

Experiential Learning

Experiential Learning

This reduced graphic demonstrates the connection between the two planes  of perception and processing – and where the learner might be – depending on the experience itself, its context, their tacit knowledge and experiences – and their learning style….

Source:   Accessed 30.10.2014

There are excellent well described explanations about the elements of this learning cycle at the James Cook University website related to Kolb’s model.  The website goes on to link the associated learning styles (highly recommended reading).

Source:   Accessed 30.10.2014

Learning styles have also been reported on in their own section.

Situated cognition theory (situated learning)

John Seely Brown, Allan Collins and Paul Duguid (1989)

 This particular theory would appear to ‘sit’ within the larger experiential learning theory.  It has social, contextual and constructivist elements in that the learning of knowledge and skills occurs in various contexts that represent and reflect the way these will be applied in the real world.

This theory encourages the immersion of learners in a learning environment that approximates as closely as possible the situation in which the new knowledge, practice or attitude will be required. This practical approach reflects a situated perspective by seeking to contextualize learning – and this closely aligns with what the intent is of simulation.

In conclusion it makes sense then to review the Experiential Learning Theory and model(s) in the context of simulation – and ask how this concept can be addressed, applied and measured.

Considerations

When developing a curriculum, course, tutorial, workshop, scenario, learning objectives/outcomes where simulation will be embedded and integral to the educational process:  Consider:

  • How and what Experiential Learning principles and learning processes will guide these developments?
  • What Experiential Learning factors are important to review and consider (this links to other education theories)?
  • Where will Experiential Learning be of benefit?
  • When will Experiential Learning be of benefit?

Consider Experiential Learning and where it intersects with:

  • The curriculum;
  • The teacher / instructor / facilitator / technician;
  • The individual learner’s learning style and characteristics (see conceptual framework theory);
  • Groups of learners;
  • Andragogy (see conceptual framework theory);
  • Heutagogy (see conceptual framework theory);
  • Tacit knowledge (see conceptual framework theory);
  • Education taxonomies and simulation;
  • Identified learning objectives and outcomes;
  • Situated learning;
  • Contextual learning;
  • Scaffolded learning;
  • Critical thinking (see conceptual framework theory);
  • Clinical reasoning;
  • Clinical judgment;
  • Feedback and debriefing (see conceptual framework theory);
  • Reflective learning (see conceptual framework theory);
  • Competency attainment (see conceptual framework theory);
  • Self-efficacy (see conceptual framework theory);
  • Expert practice (see conceptual framework theory);
  • Complexity (in learning and environment);
  • Authenticity (in learning and environment);
  • Fidelity (in learning and environment);
  • Resources (educational, human, technical, infrastructure).

6: Critical Thinking / Clinical Reasoning / Clinical Judgement

Theory

Critical Thinking Theory

Theorist(s) to consider John Dewey
Peter Facione
Noreen Facione
Carol Giancarlo

Rationale

It is reasonable to suggest that within the mix of those education theories already mentioned addressing Andragogy, Heutagogy, Tacit Knowledge and Learning styles, there is a need to consider this education theory.  It has a pivotal interconnecting role in how the learner makes sense of the education intervention and subsequently uses that learning.

Critical Thinking Theory also intersects with and facilitates the other theories and models also provided in this framework – Learning Styles, The Reflective Learner, Skills Development and Clinical Competency Attainment, development and reinforcement of Self-efficacy and ultimately Deliberate Practice towards Expert Performance.

Critical Thinking has its roots in history from Socrates onward – and attached is a brief expose’: 

Source: accessed 31.10.2014   

In earlier education theory development, John Dewey (1910; 1982), in his book How We Think, defined critical thinking as "reflective thought" indicating one needed to suspend judgment, maintain a healthy scepticism, and exercise an open mind –and that critical thinking has both an intellectual and an emotional component.  Others have also indicated this.

Source:  accessed 31.10.2014

There is any number of current definitions of Critical Thinking and it becomes problematic to provide them all in this rationale.  One quite succinct definition offered is:  

‘Critical thinking is the ability to think clearly and rationally. It includes the ability to engage in reflective and independent thinking. Someone with critical thinking skills is able to do the following:

  • understand the logical connections between ideas;
  • identify, construct and evaluate arguments;
  • detect inconsistencies and common mistakes in reasoning;
  • solve problems systematically;
  • identify the relevance and importance of ideas;
  • reflect on the justification of one's own beliefs and values.’

Source: accessed 31.10.2014

A further perspective is provided to demonstrate the varying approaches to Critical Thinking Theory:  

Source: accessed: 31.10.2014

However from a theoretical perspective the following expert consensus statement provided by Facione (1990) is offered to establish some boundaries for the theory in this context:

‘Critical Thinking: A Statement of Expert Consensus for Purposes of Educational Assessment and Instruction:  We understand critical thinking to be purposeful, self-regulatory judgment which results in interpretation, analysis, evaluation, and inference, as well as explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which that judgment is based. CT is essential as a tool of inquiry.’

The consensus statement goes on to describe what they believe to be the ideal critical thinker – and thus the need to educate good critical thinkers would indicate a need and strategy to work toward this ideal.  

There is also provided a list of Critical Thinking cognitive skills and sub-skills of which the Delphi experts found significant consensus. These are embedded in the next comment.

Source:  Facione, P. (1990). The Delphi Report. Critical thinking: a statement of expert consensus for purposes of educational assessment and instruction; California Academic Press; 1-20.  

Importantly Facione et al (1997) identify the strategic locus of critical thinking as a pivotal, essential cognitive and internally motivated  reasoning disposition process for professionals in saying;     

‘Professionals are expected to exercise sound, unbiased judgment in interpreting and analyzing information, determining the nature of problems, identifying and evaluating alternative courses of action, making decisions, and, throughout, monitoring the process and impact of their problem solving activity so as to amend, revise, correct, or alter their decisions, or any element that led up to those decisions, as deemed necessary.  Judgment in professional practice, correctly exercised, is a reflective, self-corrective, purposeful thinking process which requires the professional to take into account content knowledge, context, evidence, methods, conceptualizations, and a variety of criteria and standards of adequacy. Professional judgment is what educators have called “critical thinking” but exercised in a practical, professional setting. ‘  

While this statement encompasses what is essential to know about the core cognitive activity that is critical thinking it is also important to acknowledge there are other aspects to consider: namely how professionals, through knowledge and experience, develop and apply clinical reasoning; and through development of opinions demonstrate clinical judgement which may also include creative and intuitive thought and behaviour.             

Indeed the connectivity is aptly provided in the Lapkin et al (2010) systematic review that looked at the effectiveness of using human patient simulation manikins in the teaching of clinical reasoning skills to undergraduate nursing students; it notes that; ‘clinical reasoning (CR) is an essential component of competent [nursing] practice. It is a process that involves both cognition and metacognition (or reflective thinking) and is dependent upon a critical thinking ‘disposition’.  

Source:  Lapkin et al (2010). The effectiveness of using human patient simulation manikins in the teaching of clinical reasoning skills to undergraduate nursing students: a systematic review JBI Library of Systematic Reviews; JBL000287; 8(16): 661-694  

While this rationale section is focused on indicating the need to consider the Critical Thinking Theory in relation to simulation education, it is recommended that significant focus is given to where clinical reasoning sits in this domain.   

While there are many publications across many areas to consider, the current reference work of Tracy Levett-Jones (2013) is of contemporary significance as the material in this reference book provides a bridge to applying theory to practice in a simulation setting.  

It provides an educational model (the clinical reasoning process) designed to help identify and manage clinical issues plus number of well-designed focused scenarios that address clinical reasoning and help in triggering critical thinking and creatively in care provision. It is one of the few publications that offer an application process – based on sound educational theory. 

Source:  Accessed 31.10.2014

From a Clinical Judgement perspective Shaban (2012) provides a timely review of the theoretical literature on theories of clinical judgment and decision-making. Review of this paper will be of benefit as it demonstrates the relationship to the previous discussions.

Source: Accessed 31.10.2014

Critical Thinking Theory and its relationship to and interconnectivity with the other education theories is an important and strategic theory to consider when developing simulation activities – given the underpinning process of learning with simulation is to help trigger learners to develop those ideal critical thinking traits, to generate clinical reasoning, to make some sound and valued clinical judgements – and demonstrate competence in practice.

Considerations

When developing a curriculum, course, tutorial, workshop, scenario, learning objectives/outcomes where simulation will be embedded and integral to the educational process:  Consider:

  • How and what Critical Thinking Theory principles and learning will guide these developments?
  • What foundational factors of Critical Thinking Theory are important to review and consider (this links to other education theories)?
  • Where will Critical Thinking Theory be of benefit?
  • When will Critical Thinking theory be of benefit?

Consider Critical Thinking Theory and where it intersects with:

  • The curriculum;
  • The teacher / instructor / facilitator / technician;
  • The individual learner’s learning style and characteristics (see conceptual framework theory);
  • Groups of learners;
  • Andragogy (see conceptual framework theory);
  • Heutagogy (see conceptual framework theory);
  • Tacit knowledge (see conceptual framework theory);
  • Situated learning;
  • Contextual learning;
  • Scaffolded learning;
  • Experiential learning (see conceptual framework theory);
  • Clinical reasoning;
  • Clinical judgment;
  • Feedback and debriefing (see conceptual framework theory);
  • Reflective learning (see conceptual framework theory);
  • Complexity (in learning and environment);
  • Authenticity (in learning and environment);
  • Fidelity (in learning and environment).
  • Resources (educational, human, technical, infrastructure).

7: The Reflective learner / Guided reflection

Theory

Reflective Learning Theory

Theorist(s) to consider John Dewey
Donald Schön
Malcom Knowles
David Kolb
Carol Rodgers  

Rationale

Reflection:  The opportunity to reexamine the experience. It can be; a chronological review; or thinking upon what comes to mind first; and working through the experience from that starting point.  It is a time to review the thinking processes that took place during the events of the experience. There are three stages of reflection:

  • Awareness;
  • Critical analysis;
  • New perspective.

Note: It is important to note here in this framework that Reflective Learning Theory intersects with and has connectivity with all the previous education theories covered in the framework:  Andragogy; Heutagogy; Tacit Knowledge; Learning Styles; Experiential Learning Theory and Critical Thinking Theory.    

Reflection - as a metacognitive process (a thought ‘toolkit’) - is a pivotal and essential component of all those theories, allowing the learner to makes sense and make decisions within all these domains. It is the musing, the contemplation, the ruminating and deliberation of information received (education) that facilitates the outcomes:  the decision making and action(s).  

Most of us can relate to the concept of reflective thought and the action and outcome(s) of reflection. We do it constantly throughout our lives.   On a daily basis we receive various sensory inputs from the many environments that we interface with (e.g. emotional, human, social, cultural, communication, technology, work, political, climatic) and we receive physiological biofeedback from ourselves. We either make a series of unconscious, rapid heuristic decisions – based on repeated previous experiences (experiential learning) that we have already reflected on, problem-solved and found solutions – or we consciously reflect on that input to make sense of it and possibly come up with solutions – or not.  

Reflection allows us to make sense of what we are ‘learning’ and how we might best use that ‘learning’ to our advantage. Sometimes it causes us to modify previous ‘learning’ and decisions. We construct or deconstruct and reconstruct our thoughts, attitudes, actions and outcomes depending on the input.  

If we apply critical thinking principles and practices – that is correct thinking in the pursuit of relevant and reliable knowledge - It is reasonable, reflective, responsible, and skilful thinking that is focused on deciding what to believe or do. A person who thinks critically can ask appropriate questions, gather relevant information, efficiently and creatively sort through this information, reason logically from this information, and come to reliable and trustworthy conclusions.    

The importance of using reflective learning to teach students to apply what they have learned from one situation to the next in the context of critical thinking and decision making is well documented.  So in that sense there is a strong correlation between critical thinking, reflection and problem-solving – and that activity is easily demonstrated as an action research type cycle.

Problem Solving Process

Problem-solving requires conscious processing in a particular thought format (reflecting using critical thinking skills) to sort things out and come to new conclusions:  a clear constructivist model.  

Underpinning theories:  

From an education theory perspective the concept of reflection on an education experience as a process of improving knowledge, performance and changing attitudes is not a new concept.  There have been significant writings and research in mainstream education, with many differing views about what reflection is and how it might be encouraged – and for what purpose.  

Education theorist John Dewey reported on experience and reflection in his early publications. Dewey defined reflective thought as;   ‘active, persistent, and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusions to which it tends’  and identifies five phases or aspects of reflective thought. These embrace; suggestions where possible solutions are thought of; intellectualization of the experience into a problem; the thinking through of sequential suggestions as a hypothesis to help guide further observations, activities or gather further facts;  through reasoning the further development of the idea or supposition; and  the  validation of decided hypothesis by action(s) – be they actual or imaginative in nature.  

Source:  Accessed 01.11.2014  

Dewey’s theory of inquiry work was reviewed and built on by Donald Schön who introduced notions such as ‘the learning society’, ‘double-loop learning’, the ‘reflective practitioner’, ‘reflection-in-action’ and ‘reflection–on-action’, which have become part of the language of education and now increasingly in the simulation community.  

Source:  Accessed 01.11.2014 

Andragogy & Experiential Learning – and Reflection

The adult learning concept of Andragogy as developed by Malcom Knowles requires the adult learner to identify their learning needs and requirements, their preferred ways and processes of learning, the  relevance of their learning to their development - and reflect on these (see Theory 1). In David Kolb’s Experiential Learning Theory, people learn in a cycle consisting of four stages; consisting of concrete experience; observation and reflection; forming abstract concepts; and the testing of those abstracts in new situations (see Theory 4). Both of these well developed and reported theories support the need for reflection to be an essential component of the learning process.  

Carol Rodgers, who draws on the work of Dewey and others, takes reflection further suggesting it is important that educators need to be reflective in their own role and as a community of teachers to ensure teachers develop the skills of establishing a student-focused learning environment. Using a four-phase reflective cycle, Rodgers looks at the roles of presence, description, analysis, and experimentation.  Rodgers also encourages the use of structured feed-back to ensure teachers are teaching appropriately and meeting student’s learning needs.  Rodgers, referring to Schön and the reflective cycle, also recognizes reflection can happen in the midst of experience (reflection-in-action) or outside an experience (reflection-on-action).

Source: Accessed 02.11.2014

As such Reflective Learning Theory intersects with and supports healthcare simulation education.  How the process of reflection is embedded in simulation is predominantly through the use of debriefing and feedback frameworks / models and processes.

Constructive Feedback and Debriefing – and Reflection

Feedback and debriefing are education strategies that rely on the use of reflection to attain learning outcomes.  The medical and nursing education and simulation literature is now increasingly suggesting that more significant learning occurs in the period immediately following the termination of the simulation scenario.

This is where constructive debriefing commonly occurs and it is during this phase of patient simulation where insight into the clinical issue is made explicit through reflection.  It is also suggested that the value of the participants learning is in the participant’s ability to engage in reflection on practice, which in turn more importantly translates into actionable knowledge.   Thus debriefing provides opportunities to foster reflective learning, encompassing the ability to think-in-action as well as think-on-action (Schön, 1983).

Reflective Learning

This action research format graphic demonstrates that during/post simulation reflection through debriefing leads to a cyclical constructivist change process.  

Reflection Variables in simulation

  • Relection in action
    Facilitation with ongoing discussions during a session
  • Reflection on action
    Facilitated group discussion after a simulation scenario
  • Reflection on action
    Video assisted discussion following a simulation scenario
  • Reflection before action
    Individual approach to same/similar clinical experience

Debriefing Frameworks and Models – and simulation

As simulation education develops and matures there is increasing interest in the development and application of a more strategic educational approach to facilitating reflection using debriefing.  From the initial reporting in the simulation literature of a dearth of educationally driven debriefing occurring, there are now many different debriefing techniques available to consider and there is increasing research around and validated evidence-based models now in use.    

What does Feedback & Debriefing provide:

  • Assists and augments the experiential element;
  • Reflective learning is recognized as a powerful education strategy;
  • In the scenario setting it is the best facilitation process for individual reflection while also encouraging group reflection around the learning activity;
  • It allows for constructive performance feedback;
  • The review process allows review of learning objectives and identifying linkage to outcomes;
  • It provides the linkage back to the reality of clinical practice, operational and systems processes, individual and organisational responsibilities and accountabilities;
  • It allows for reinforcement of evidence in practice.  

Debriefing Frameworks and Models  

The design of this conceptual framework is not to provide definitive debriefing frameworks / models but rather to recommend a review and reflection on how Reflective Learning can be best used in healthcare simulation education.  However there are some activities / frameworks / models provided here as examples to demonstrate current developments:  

The reporting of the use of an underpinning education theory by Waxman and Telles (2009) during the development of a simulation strategy in the USA is worth highlighting:  The Use of Benner’s Framework in High-fidelity Simulation Faculty Development:  The Bay Area Simulation Collaborative Model. This is demonstrating the theory – design connection now being identified as important by others.  

Source: Accessed 02.11.2014

In Australia the Council Of Australian Governments (COAG) sponsored Health Workforce Australia (HWA) national simulation strategy saw significant investment in training a significant number of education and clinical personnel in the essentials of simulation which includes debriefing strategies using various debriefing models.  

These include for example:  Pendleton; Chronological Review; Simulation-Based Assessment; Interactive Feedback; Calgary-Cambridge Observation Guide; SET-GO; Advocacy Enquiry; Objective Structured Assessment of Debriefing (OSAD) Plus/Delta; SHARP.  Leaners are exposed to these models in the workshops delivered nationally.  

Source: Accessed 02.11.2014

New modules: Debriefing

From a medical education perspective the Imperial College in London has produced a handbook - The London Handbook for Debriefing: Enhancing performance debriefing in clinical and simulated settings – in which two well-developed debriefing models are provided [SHARP and OSAD].

Source: Accessed 02.11.2014

There has been significant work developed at the Centre for Medical Simulation (CSM) in the USA in the use of the Advocacy Enquiry debriefing model in initial Simulation Instructor training programs and the use of a tool to evaluate debriefers:  The Debriefing Assessment for Simulation in Healthcare© (DASH©) tool.

Source: Accessed 02.11.2014   

Of interest the following link demonstrates others are building on the Advocacy Enquiry model 

Source: Accessed 02.11.2014

Kristina Thomas Dreifuerst has developed and carried out doctoral research in efforts to improve the use of debriefing in simulation: Her framework, Debriefing for Meaningful Learning©: A Reflective Strategy to Foster Clinical Reasoning which looked at the development of clinical reasoning in nursing students, is now being applied in other education precincts. Further reading is recommended.  

Source: Accessed 02.11.2014   

Any number of other examples of debriefing frameworks and models from around the world could be included here but that is not the intent. It is however recommended you follow up with further reading and review as to the most appropriate debriefing frameworks / models that you can build into your simulation curriculum / course / scenario.

It is also important to acknowledge that there are now many education and research publications relating to debriefing in simulation and any number of simulation centres that have debriefing as a core process in their simulation education activities – but it is important to reiterate that the underpinning education theory that needs to be considered and catered for is Reflective Learning  and what might be the most effective way of achieving that in simulation – especially in relation to the other theories covered in this framework .

Considerations

When developing a curriculum, course, tutorial, workshop, scenario, learning objectives/outcomes where simulation will be embedded and integral to the educational process:  Consider:

  • How and what Reflective Learning principles will guide these developments?
  • What foundational Reflective Learning factors are important to review and consider (this links to other education theories)?
  • Where will Reflective Learning be of benefit?
  • When will Reflective Learning be of benefit?

Consider Reflective Learning and where it intersects with:

  • The curriculum;
  • The teacher / instructor / facilitator / technician;
  • The individual learner’s learning style and characteristics (see conceptual framework theory);
  • Groups of learners;
  • Andragogy (see conceptual framework theory);
  • Heutagogy (see conceptual framework theory);
  • Tacit knowledge (see conceptual framework theory);
  • Situated learning;
  • Contextual learning;
  • Scaffolded learning;
  • Experiential learning (see conceptual framework theory);
  • Critical thinking (see conceptual framework theory);
  • Clinical reasoning;
  • Clinical judgment;
  • Feedback and debriefing (see conceptual framework theory);
  • Complexity (in learning and environment);
  • Authenticity (in learning and environment);
  • Fidelity (in learning and environment)
  • Resources (educational, human, technical, infrastructure).

8: Skill Development and Clinical Competence

Theory

Novice to Expert Theory

Theorist(s) to consider David Kolb
Donald Schön
Stuart E. Dreyfus and Hubert L. Dreyfus
Patricia Benner
George Miller

Rationale

From birth, humans are on a learning journey. From babyhood, through infancy, childhood, adolescence, onto adulthood and into our senior years we are constantly exposed to any number of social, cultural, educational, political and other learning activities.  They may be simple or complex, academic or technical, mental or physical depending on the circumstances.  

Out of those early pedagogical-based learning processes, with reflection and repeated responses / actions we move from novices to varying levels of expertise - walking, talking, reading, writing, sports - and onto even more complex knowledge and skills development occurs. As adolescent - adults we continue to move along the novice to expert continuum. More competitive sports, studying / training for careers, trades and professions all have us starting with little knowledge and skills but over time and repeated experience,  expertise – demonstrated as being competent or even expert – comes to the fore.  

Note: It is important to note here in this framework that intersects with and has connectivity with all the previous education theories covered in the framework:  Andragogy; Heutagogy; Tacit Knowledge; Learning Styles; Experiential Learning Theory; Critical Thinking Theory; and Reflective Learning Theory.  Novice to Expert Theory requires these other theories to be underpinning and addressing educational activities so that learners are in the right ‘situation’ to benefit  

So when considering the professional development of healthcare personnel towards being appropriately prepared for their engaging in their various disciplines it is acknowledged there will be also a continuum of learning: from initial knowledge, skill and attitudinal acquisition to increasing levels of maturity of thought, knowledge, skill, competence and advanced expertise (experts). Indeed there is significant education commentary and research literature and reference books on this education theory – and it goes beyond this framework to encompass this evidence.

What is important is to comment on the pivotal theorists who have helped set the stage for this theory to be an important, strategic theoretical adjunct to be considered when developing simulation education activities.

First it is essential to revisit David Kolb’s Experiential Learning Theory which establishes four distinct learning styles -or preferences - which are based on his four-stage learning cycle. Understanding Kolb's model allows us to understand that there are individual learning styles, and that the cycle of experiential learning applies to all learners – including novices to experts.

It is also important to momentarily revisit Donald Schön who introduced notions such as ‘the learning society’, ‘double-loop learning’, the ‘reflective practitioner’, ‘reflection-in-action’ and ‘reflection–on-action’, for it is those processes that help a novice move forward along the continuum and indeed allow an expert to sustain or increase expertise.

However it is the works of Stuart and Hubert Dreyfus and the Dreyfus model of skill acquisition - a five-stage novice to expert model describing the mental activities of perception, learning and reasoning involved in directed skill acquisition - which has been established as a now well applied education theory that has been commented on, critiqued, documented, described and applied. Pena (2010) has provided a critical perspective that is worth reviewing as he offers critique by others and offers alternative views to their propositions.

Source: Accessed: 03.11.2014

From its original perspective the Dreyfus Model was taken up by Patricia Benner and applied in the healthcare profession of nursing. Here too there has been significant research, publication, commentary, challenge and contextualisation. Yet it prevails as a validated and reliable education theory that guides curriculum and educational activities. It certainly has found its way into the simulation education arena and so it is reasonable to continue to consider it when developing simulation programs.  Primarily it is important to understand where your learners are coming from – from a knowledge and practice perspective – and design appropriately.

Source: Accessed: 03.11.2014

Another theorist needing mention in the context of moving from novice to expert, including attaining competency and achieving mastery is George Miller and his Pyramid / Prism of Clinical Competence (1990). He proposed a framework for assessing levels of clinical competence that included the following:

  • Knows [knows some knowledge]
  • Knows how [knows how to apply that knowledge]
  • Shows [shows how to apply that knowledge]
  • Does [actually applies that knowledge in practise]

Novice to Expert

This is best demonstrated in the following graphic.  It demonstrates the different levels of cognition and behaviour assessed and where that occurs on the novice to expert continuum.

Novice to Expert

Source:  Accessed 11.11.14 

Applications

As previously stated it is not the intent of this framework in each section to provide a prescriptive list of what work has been undertaken with a particular education theory. That becomes your task to make the theory-practice connection others have or how you can. However in this instance – because this process is so central to healthcare professional development with most disciplines – here are some examples:

As recognized in the Reflective Learning Theory, the reporting of the use of this underpinning education theory by Waxman and Telles (2009) during the development of a simulation strategy in the USA is worth highlighting: The Use of Benner’s Framework in High-fidelity Simulation Faculty Development: The Bay Area Simulation Collaborative Model. This is demonstrating the theory – design connection now being identified as important by others.

Source: Accessed 02.11.2014

Abstract: Traynor et al (2010). From novice to expert: using simulators to enhance practical skill.

Source: Accessed 02.11.2014

And as a bonus this publication indicates similar thinking where they broach the same question regarding theoretical models and simulation education.

Sadideen & Kneebone (2012). Practical skills teaching in contemporary surgical education: how can educational theory be applied to promote effective learning?

Source: Accessed 02.11.2014

Abstract:

Scaffolding:

Definition

Source: Accessed 02.11.2014

Of course it is here where scaffolding as a curriculum / program education strategy comes into play. While scaffolding is not an education theory it is an important educational process – a teaching method - that helps learners. Depending on where the learners are on the continuum as to how much or how little scaffolding is provided.

While considering this pivotal theory there is also evidence that novices learn differently to experts. So while it is important to have a good grasp of the Novice to Expert Theory it is also important to know that this is a theory is constantly under review. Daley in her research Novice to Expert: How do professionals learn? reports that novices learn in quite different ways to experts. Addressing this factor is vital in your planning.

Source: Accessed: 03.11.2014

In conclusion there is a further factor that needs to be considered within the context of this theory. Just because a clinician achieves a certain level of expertise does not mean he or she will automatically maintain that level. There are many mitigating reasons why expertise may be negatively impacted on - and they can be pursued through analyses.

However while simulation can be of value to help the novice develop along the journey to competence and expertise, simulation also becomes a strategic process to mitigate knowledge and skill decay - and to maintain confidence and self-efficacy – a further education theory.

Considerations

When developing a curriculum, course, tutorial, workshop, scenario, learning objectives/outcomes where simulation will be embedded and integral to the educational process: Consider:

  • How Novice to Expert Theory will guide these developments?
  • What Novice to Expert Theory factors are important to review and consider (this links to other education theories)?
  • Where will Novice to Expert Theory be of benefit?
  • When will Novice to Expert Theory be of benefit?

Consider Novice to Expert Theory and where it intersects with:

  • The curriculum;
  • The teacher / instructor / facilitator / technician;
  • The individual learner’s learning style and characteristics (see conceptual framework theory);
  • Groups of learners;
  • Andragogy (see conceptual framework theory);
  • Heutagogy (see conceptual framework theory);
  • Tacit knowledge (see conceptual framework theory);
  • Situated learning;
  • Contextual learning;
  • Scaffolded learning;
  • Experiential learning (see conceptual framework theory);
  • Critical thinking (see conceptual framework theory);
  • Clinical reasoning;
  • Clinical judgment;
  • Feedback and debriefing (see conceptual framework theory);
  • Reflective learning (see conceptual framework theory);
  • Complexity (in learning and environment);
  • Authenticity (in learning and environment);
  • Fidelity (in learning and environment)
  • Resources (educational, human, technical, infrastructure)

9: Self-efficacy

Theory

Self-efficacy

Theorist(s) to consider Albert Bandura

Rationale

Why is it important that humans need to feel ‘good’ about themselves and how they do things – whether thinking, relating, communicating, socialising, actioning and responding – to the environment and all that this implies? How is it that some humans seem to learn easily, take on complex information or tasks and achieve positive outcomes?

While these questions have a significant psychology orientation with a range of potential theoretical underpinnings – there is significant research and publications on personality factors, traits and a whole range of other psychological perspectives – more importantly the more pertinent questions to ask are:   why is Self-efficacy an important education theory to consider?  And why is this important from a simulation education perspective?

What is Self-efficacy?  One of the most prolific authors in this area is Albert Bandura. 

Of all the explanations one might garner, Bandura (1994) provides a sound definition:  

‘Perceived self-efficacy is defined as people's beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives. Self-efficacy beliefs determine how people feel, think, motivate themselves and behave. Such beliefs produce these diverse effects through four major processes. They include cognitive, motivational, affective and selection processes.’

Bandura (1994) goes on to explain the positive traits, behaviours and outcomes of someone with a strong sense of efficacy  / high assurance in themselves and their capabilities, as opposed to those who have a lesser assurance, with self-doubt , lowered aspirations, who believe they are deficient and as result do not achieve set goals. They also give up more easily and find it hard to recover their sense of efficacy.  

Of course it is important to mitigate these issues where possible from any educational perspective. I recommend further reading of Bandura’s work especially where he comments on:  sources of Self-Efficacy Beliefs; Efficacy-Mediated Processes; Adaptive Benefits of Optimistic Self-Beliefs of Efficacy; and Development and Exercise of Self-Efficacy Over the Lifespan. All of these are relevant in the use of simulation education.  

Source:  Accessed 04.11.2014

With that in mind then it is also incumbent to reflect on where Self-efficacy theory intersects with and relates to all the previous education theories covered in the framework to date:  Andragogy; Heutagogy; Tacit Knowledge; Learning Styles; Experiential Learning Theory; Critical Thinking Theory; Reflective Learning Theory and Novice to Expert Theory.  

It would make logical sense then that if some or all of these theories are considered / embedded – or even new ones introduced - during simulation curriculum development and course delivery, that the opportunities for impacting positively on a learner’s experience would in turn establish the best opportunities for positive efficacious outcomes – using simulation.

Inclusive and effective addressing of these before and during simulation education activities would ensure learners are in the most effective learning environment to benefit –given that the other elements of simulation itself as a teaching and learning method are addressed in design, execution and evaluation. Such planning and implementation would encourage a feed-back loop that would encourage / enhance self-efficacy -as the learner’s needs are achieved and they continue to reflect on those outcomes in a positive constructivist way.  

There is research underway in this area as more educators identify the need to address Self-efficacy in the preparation of healthcare professionals – using simulation. Here are examples of that:

Cardoza & Hood (2012). Comparative study of baccalaureate nursing student self-efficacy before and after simulation .

Source:  Accessed 04.11.2014

A Master of Science research proposal by Boeglin, A. (2012).  Student’s level of self-efficacy obtained with clinical simulation:  The purpose of this study is to determine if self-efficacy in student nurses is increased by use of high-fidelity simulation (HFS) as a teaching/learning method.

Source:  Accessed 04.11.2014

There are other works for review in this domain and it is recommended they are sort out and reviewed - to gain further knowledge and expertise - as to how best look at applying Self-efficacy theory into simulation education.

 In conclusion it is also important to ensure – when applying this education theory – that the focus is right and what you end up measuring is as effective as it can be.  In a recent publication, the author points out there remains in the research being undertaken and reported on that there is some disconnect between what is intended to be measured and what outcomes are identified. Specifically this is around researchers identifying the inability of participants to demonstrate effective psychomotor and/or higher order cognitive skills even though the same participants report they are very confident that they are performing well.

Kardong-Edgren, S. (2013). Bandura's self-efficacy theory…something is missing, Clinical Simulation In Nursing, Sept. 9(9); e327–e328.

Source:  Accessed 04.11.2014 

So it becomes incumbent on any person considering the embedding of and researching of this theory, to identify what and how this might be delivered and measured. Remembering that it has strong connectivity to the other theories already identified – and maybe should not be considered in isolation – as so many education theories are.

Considerations

When developing a curriculum, course, tutorial, workshop, scenario, learning objectives/outcomes where simulation will be embedded and integral to the educational process:  Consider:

  • How and what Self-efficacy principles will guide these developments?
  • What Self-efficacy factors are important to review and consider (this links to other education theories)?
  • Where will Self-efficacy theory be of benefit?
  • When will Self-efficacy theory be of benefit?

Consider Self-efficacy theory and where it intersects with:

  • The curriculum;
  • The teacher / instructor / facilitator / technician;
  • The individual learner’s learning style and characteristics (see conceptual framework theory);
  • Groups of learners;
  • Andragogy (see conceptual framework theory);
  • Heutagogy (see conceptual framework theory);
  • Tacit knowledge (see conceptual framework theory);
  • Situated learning;
  • Contextual learning;
  • Scaffolded learning;
  • Experiential learning (see conceptual framework theory);
  • Critical thinking (see conceptual framework theory);
  • Clinical reasoning;
  • Clinical judgment;
  • Feedback and debriefing (see conceptual framework theory);
  • Reflective learning (see conceptual framework theory);
  • Complexity (in learning and environment);
  • Authenticity (in learning and environment);
  • Fidelity (in learning and environment)
  • Resources (educational, human, technical, infrastructure)

10: Deliberate Practice and Acquisition of Expert Performance

Theory

Deliberate Practice and Acquisition of Expert Performance

Theorist(s) to consider K. Anders Ericsson

Rationale

This education theory is an important one in the sense it supports the notion that, given other education and learning factors are in place, there comes a time and place / opportunity where the learner moves into a further learning and achieving plane. It might be generated by the learner or it might be provided externally through an organised process that facilitates the acquisition of expert knowledge, skills, attitude and performance.

What is important to recognize is the difference between practice where expert skills are honed and made more permanent / maintained to the focused effort concept of Deliberate Practice. It is this process that enables expert performance to be demonstrated – whether it be in music, acting, medicine, nursing, allied health, sports, games that require metacognitive skills, or any number of work / professional profiles that make the performer stand out from other experts.

Ericsson et al (1993) raise and discuss this phenomenon, presenting a theoretical framework that describes expert performance as; ‘the end result of individuals' prolonged efforts to improve performance while negotiating motivational and external constraints.’ They go on to say that ‘in most domains of expertise, individuals begin in their childhood a regimen of effortful activities (deliberate practice) designed to optimize improvement. Individual differences, even among elite performers, are closely related to assessed amounts of deliberate practice. Many characteristics once believed to reflect innate talent are actually the result of intense practice extended for a minimum of 10 years. Analysis of expert performance provides unique evidence on the potential and limits of extreme environmental adaptation and learning.’

Source: Accessed 02.11.2014 Ericsson, K.A., Krampe, R. Th. and Tesch-Romer, C. (1993). The Role of deliberate practice in the acquisition of expert performance, Psychological review, 100(3); 363-406.

Again Ericsson (2008) reviews Deliberate Practice and Acquisition of Expert Performance and reports on the scientific study of expert performance and its acquisition; where the principles of Deliberate Practice and Acquisition of Expert Performance established in other domains such as sport, chess, music and typing to gain insight into developing expert performance in healthcare.

Ericsson discusses the time / deliberate practice processes used to measure individual performance acquisition of superior reproducible (expert) performance across different domains of expertise indicating it is possible to measure the time course of improvement. However In some domains there is no demonstrable improvement in performance as a function of years of professional experience [in healthcare preparation] (examples are provided) while traditional domains of expertise, such as arts and sciences, games, and sports, demonstrate improvements that appear to continue for decades.

Ericsson looked at the differences between mere experiences versus deliberate practice in efforts to reconcile the differences identified. The researchers identified those domain-related activities necessary for improving performance and classified them as deliberate practice. Then, based on a review of research on skill acquisition, a set of parameters were identified where practice had been uniformly associated with improved performance.

According to Ericsson (2008) this improvement come about when individuals were, ‘given a task with a well-defined goal; motivated to improve; provided with feedback; and provided with ample opportunities for repetition and gradual refinements of their performance, ’ which are factors that emanate from other educational underpinnings.

Ericsson

This graph reproduced from Ericsson (2008) demonstrates the cause and effect of everyday activities, as opposed to improvement of expert performance. Some experts peak, give up and decline, while others continue to engage in deliberate practice to attain expert performance. What is not identified is the plethora of real and potential factors that impact on this phenomenon.

Source: Ericsson K. A. (2008). Deliberate practice and acquisition of expert performance: a general overview, Academic emergency medicine. 15: 988–994

This brings the discussion back to the education theories already broached in this framework and where they may individually or collectively play a part in supporting this particular theory – and whether this theory in some ways relies on the other theories to be in place to support, if not legitimize, it.

From a constructivist perspective the learner / practitioner will be constantly going through the cycle of construct / deconstruct / reconstruct as the deliberate practice process will require new inputs, change or modification in practice, new boundaries and challenges be they physiological, psychological, political, social, or cultural in nature. Depending on the environment, challenges and opportunities (self-made or provided) the learner / practitioner will be adapting –with deliberateness – to achieve even more expert outputs. There are any number of examples of individuals in sport, music and acting, in science and humanities, writers and researchers who have through deliberate practice achieved what others would consider phenomenal outcomes.

With that in mind it becomes obligatory to reflect also on where Deliberate Practice and Acquisition of Expert Performance intersects with and relates to the other education theories covered in the framework. It becomes self-evident there is a strong correlation and connectivity between:

  • Andragogy (adult learning) and Deliberate Practice and Acquisition of Expert Performance:
  • Heutagogy (self-determined learning) and Deliberate Practice and Acquisition of Expert Performance;
  • Tacit Knowledge (previous knowledge and experience) and Deliberate Practice and Acquisition of Expert Performance;
  • Learning Styles Deliberate Practice and Acquisition of Expert Performance;
  • Experiential Learning Theory Deliberate Practice and Acquisition of Expert Performance;
  • Critical Thinking Theory Deliberate Practice and Acquisition of Expert Performance;
  • Reflective Learning Theory and Deliberate Practice and Acquisition of Expert Performance;
  • Novice to Expert Theory and Deliberate Practice and Acquisition of Expert Performance; and,
  • Self-efficacy and Deliberate Practice and Acquisition of Expert Performance.

That is not to say that Deliberate Practice and Acquisition of Expert Performance necessarily requires all those education theories to be in place for a learner to become an expert - but it could be hypothesised that the more the connectivity the better the opportunities - for the learner to remain committed to excel at becoming an expert.

Deliberate Practice and Acquisition of Expert Performance – and Simulation

Some examples:

Is there benefit using simulation and Deliberate Practice strategies? McGaghie et al (2011) reports on this in their 20 year literature review and meta-analysis: Does Simulation-based Medical Education with Deliberate Practice Yield Better Results than Traditional Clinical Education? A Meta-Analytic Comparative Review of the Evidence

Source: Accessed 02.11.2014

Udani et al (2014) has published a research article where they demonstrate simulation-based mastery learning with deliberate practice improves clinical performance in spinal anesthesia. They also reference similar work.

Source: Accessed 02.11.2014

Causer et al (2014) also see a place for Deliberate Practice in simulation with their recent publication: Expertise in medicine: using the expert performance approach to improve simulation training.

Source: Accessed 02.11.2014

These examples and an increasing number of other presentations are being published that subscribe to the notion – the education theory – of Deliberate Practice and Acquisition of Expert Performance has a role in simulation education. This is promising but at the same time once again only one education theory is being considered when there are others underpinning and supporting the simulation education experience being developed and delivered. Does that limit the experience and impact on outcomes?

This is an important consideration and the conceptual framework is designed to both trigger that and provide a process to help plan effective educationally sound simulation interventions.

Considerations

When developing a curriculum, course, tutorial, workshop, scenario, learning objectives/outcomes where simulation will be embedded and integral to the educational process: Consider:

  • How and what Deliberate Practice and Acquisition of Expert Performance criteria will guide these developments?
  • What Deliberate Practice and Acquisition of Expert Performance factors are important to review and consider (this links to other education theories)?
  • Where will Deliberate Practice and Acquisition of Expert Performance be of benefit?
  • When will Deliberate Practice and Acquisition of Expert Performance be of benefit?

Consider Deliberate Practice and Acquisition of Expert Performance and where it intersects with:

  • The curriculum;
  • The teacher / instructor / facilitator / technician;
  • The individual learner’s learning style and characteristics (see conceptual framework theory);
  • Groups of learners;
  • Andragogy (see conceptual framework theory);
  • Heutagogy (see conceptual framework theory);
  • Tacit knowledge (see conceptual framework theory);
  • Situated learning;
  • Contextual learning;
  • Scaffolded learning;
  • Experiential learning (see conceptual framework theory);
  • Critical thinking (see conceptual framework theory);
  • Clinical reasoning;
  • Clinical judgment;
  • Feedback and debriefing (see conceptual framework theory);
  • Reflective learning(see conceptual framework theory);
  • Complexity (in learning and environment);
  • Authenticity (in learning and environment);
  • Fidelity (in learning and environment)
  • Resources (educational, human, technical, infrastructure).
© Copyright 2014 Irwyn Shepherd: Click here for the bibliography