The health care system is increasingly complex, requiring health care students to develop teamwork and communication skills beyond those previously required (Orchard, Curran, & Kabene, 2005). Effective teamwork among health professions has demonstrated positive effects on patient outcomes (D’Amour, Ferrada-Videla, San Martín-Rodrígues, & Beaulieu, 2005; Oandasan et al., 2006; Reeves & Freeth, 2002). Research supports interprofessional education (IPE) initiatives as being effective in improving students’ knowledge, skills, and attitudes about interprofessional teamwork (Hammick, Freeth, Koppel, Reeves, & Barr, 2007; Reeves & Freeth, 2002). Therefore, the adoption of IPE in health care student training programs has been widely promoted (Barr, Koppel, Reeves, Hammick, & Freeth, 2005; Health Council of Canada, 2006; Herbert, 2005).
The Lancet Commission (Frenk et al., 2010
) conducted a global review of health professionals to reexamine its current state and to suggest a redesign. Frenk et al. (2010
) suggested that achievement of this vision is guided by two outcomes: (a) interinstitutional collaborations or interdependence in education and (b) transformative learning. Transformative learning is characterized by engagement in critical thinking and consideration of ethical conduct. According to Frenk et al. (2010
Transformative learning involves three fundamental shifts: from fact memorisation to searching, analysis, and synthesis of information for decision making; from seeking professional credentials to achieving core competencies for effective teamwork in health systems; and from non-critical adoption of educational models to creative adaptation of global resources to address local priorities. (p. 1924)
The dynamic and interpersonal nature of teamwork and collaboration calls for the use of experiential and interactive educational approaches (Curran, Sharpe, Flynn, & Button, 2010). Highly realistic, simulation-based training (SBT) provides an experiential learning context in which students develop clinical and interprofessional team skills in a safe and controlled environment (Issenberg, McGaghie, Petrusa, Lee Gordon, & Scalese, 2005; McCallum, 2007; McGaghie, Issenberg, Petrusa, & Scalese, 2010; Rhodes & Curran, 2005). Evidence also shows that interprofessional simulations can further promote collaboration and enhance clinical decision making (Maxson et al., 2011; Miller, Riley, Davis, & Hansen, 2008), as well as provide an educational tool that supports patient safety (Rosen et al., 2008). As a result, SBT has become best practice in IPE (Robertson & Bandali, 2008). IPE SBT may be particularly important for prelicensure students who have few real-life experiences as members of interprofessional teams. However, without previous experiences to ground their learning, students may consider IPE initiatives irrelevant or detrimental (Anderson, Smith, & Thorpe, 2010; Hammick et al., 2007).
This article proposes a systematic process for improving the relevance and validity of learning objectives (LOs) of interprofessional SBT using video review and follow-up student interviews. The revised LOs were divided into those for the simulation itself and different LOs for the debriefing. This structure was more appropriate for the design, debriefing, and evaluation of prelicensure interprofessional health team simulation for students achieving core interprofessional competencies.
SBT provides opportunities to learn IPE competencies at various stages of the simulation (Miller et al., 2008). For example, opportunities for reflective practice are present throughout the stages of simulation but may be best learned during the debriefing (Mann, Gordon, & McLeod, 2007). The degree to which learning occurs is linked to instructional design considerations and the development of LOs from competency statements (Stewart, Kennedy, Cuene-Grandidier, 2010).
Competency Statements to Learning Objectives
Competency statements are often broad and difficult to apply to LOs. In addition, identifying markers of a satisfactory performance for psychomotor skills is comparatively straightforward when compared with markers of a satisfactory performance for teamwork and communication. Effectiveness results from well-defined methods of translating competencies into LOs and modifying LOs based on student learning and feedback (Frenk, et al., 2010).
A competency-based approach to learning requires the identification of competencies required for graduates to address the patient concerns they are likely to face and tailors the curriculum to achieve those competencies (Rosen et al., 2008). Identifying LOs, which determine design decisions, is important in both the simulation and the debriefing (Stewart et al., 2010; Wu & Shea, 2009).
In 2008, in reference to graduate medical education, Rosen et al. proposed “a generalizable methodology for systematically linking scenario development, performance measurement, and feedback to explicitly defined LOs rooted in...core competencies” (p. 1190). Their method minimizes the gaps between competency statements, LOs, learning outcomes, and assessment, and it uses the outcomes to revise the LOs to maintain or improve the validity of the learning experience. However, the specifics of how to use outcomes to revise LOs are unclear.
The Interprofessional Health Education Partnership is a joint initiative between four post-secondary institutions and a provincial health provider in a large western Canadian city. The partnership developed a series of interprofessional health team simulations, one of which was titled “Postoperative Teamwork and Communication: Anaphylaxis that was manikin-based. The simulated case was developed with LOs based on the Canadian Patient Safety Institute’s safety competencies (Frank & Brien, 2008). Table 1 includes a summary of the original LOs. At the time the LOs were developed, the Canadian Interprofessional Health Collaborative had not yet published their competency framework. The project educators have since mapped the case LOs onto the Canadian Interprofessional Health Collaborative competencies, which are not reported in this article.
Table 1: Original and Revised Learning Objectives for the Postoperative Teamwork and Communication: Anaphylaxis Simulation
Prelicensure students participated in the interprofessional SBT Postoperative Teamwork and Communication: Anaphylaxis early in their programs prior to working in actual health teams. The simulations were extracurricular, and the objective of the simulations was formative learning. Students were provided with an orientation to the context, case, and simulation tools. Student teams were recruited from the following programs:
- Practical nursing (2-year diploma program at a community college).
- Bachelor of nursing (4-year degree programs at two different universities).
- Medicine (prelicensure program at a university).
- Respiratory therapy (3-year diploma program at a polytechnical institute).
Following pilot testing of the simulation, a systematic evaluation of the LOs was completed based on data collected during the pilot testing.
The types of data collected were identified as those that would best provide the researchers with rich information about students’ experiences in the simulation, the types of learning that occurred, and the process by which learning occurred. The sources of data in this project included:
- Video recordings of simulations (total of three videos).
- Video recordings of debriefings of simulations (total of three videos).
- Student follow-up telephone interviews. Telephone interviews were identified as the most appropriate interview method because many of the students had changed locations since the original event due to placements (total of 30 interviews).
This project was approved by the university’s health research ethics board. All participants provided informed consent, and data reported are not identifiable.
A rigorous iterative process was undertaken to identify the formative learning in the simulation. The multistep process involved immersion in the data and analysis of the video and the student interview data, resulting in a model of mapping the evidence of interprofessional teamwork and communication skills learned at various stages in the simulation.
Step 1: Immersion in Simulation Data. The Canadian Patient Safety Institute’s (Frank & Brien, 2008) guidelines on competencies for enhancing patient safety in interprofessional team settings was used to outline the communication and teamwork competencies that health professionals are expected to maintain. The enabling competencies were:
- Omitted when they were not relevant.
- Reworded to reflect more active wording.
- Conceptualized to apply to simulation, debriefing, and follow-up learning contexts.
The competencies originally included the Canadian Patient Safety Institute’s competencies from domains two and three and were reduced through this process to the final four competencies that were the revised LOs. Theories of reflection (Mann et al., 2007) and taxonomy (Bloom, 1956) in terms of LOs inform the development and refinement of learning at each stage (Table A; available as supplemental material in the online version of this article).
Step 2: Analysis of Video and Student Interview Data: Refining and Establishing Validity of the LOs Used in the Simulation. Using the competency worksheet, the videos of the interprofessional health education partnership modules were viewed by two researchers (raters; E.G., T.L.), and instances of a learning opportunity pertaining to a particular competency-based learning objective in each stage of the simulation were noted. The raters then reviewed the videos of the debriefings, noting indicators of learning outcomes in the discussions within the student teams and in the feedback provided by the facilitators. The final step in confirming the validity of the coding was the follow-up telephone interviews with the students. The students were asked specifically what they remembered about the simulation and debriefing that was helpful for them in learning about teamwork and communication. Transcripts from the student follow-up interviews were reviewed, and instances relating to the competencies were counted and totaled in the final column of the worksheet.
Refining the LOs
Table A outlines the stages of simulation and the types of reflection described by Mann et al. (2007). Table 2 presents modifications to the learning objectives as they relate to the stages of simulation. These two tables summarize several documents used throughout the process to clarify the relationship between competency statements and learning objectives at each stage of the simulation process. Table 3 represents an outline of this process, which can be used by other educators.
Table 2: Learning Objectives in the Postoperative Teamwork and Communication: Anaphylaxis Interprofessional Simulation Related to Bloom’s Taxonomy and Stages of Simulation
Table 3: Revising Learning Objectives (LOs) for Interprofessional Education Simulation-Based Learning
The iterative process provided information on the competencies that are most frequently and best practiced, taught, or reinforced in the simulation and debriefing. It was found that the competencies observed in the simulations were not always those identified in the original LOs. In some cases, there were fewer opportunities to meet the LOs within the simulation than the designers had intended. For example, one LO was “delegates tasks appropriately.” Although there were ample opportunities for the delegation of tasks within the simulation, students did not always engage in the behaviors of delegation within the simulation due to either the absence of a key team member or the personalities and clinical experiences of the team members who were in the simulation. Consequently, simulations could be modified to better meet existing LOs in cases where the simulation is curricular, rather than co-curricular. For the simulation under review in this study, the LOs were revised.
In addition, the original LOs were thought to apply to the entire simulation. However, through the process of reviewing these simulations, it became clear that separate LOs for the simulation and debriefing sections serve to enhance higher levels of learning by focusing on reflective processes in the debriefing. This delineation provides a basis for instructors to facilitate transformative learning processes (Frenk et al., 2010). Table 2 shows a summary of LOs modified to apply to stages of simulation. By having separate LOs for reflection and discussion in the debriefing component, transformative learning is supported. Table 1 summarizes the original and revised LOs in this simulation.
Results and Discussion
Relevant Interprofessional Learning at a Prelicensure Level
Despite the importance of learning interprofessional team-work and communication skills, students who have no experience working in teams with other disciplines may not consider interprofessional learning relevant. Our study supports the finding of other research that for interprofessional learning to occur, the learning experiences must be perceived by the students as relevant (Jeffries & Rizzolo, 2006). Therefore, interprofessional simulation can provide prelicensure students with exposure-level experiences to make relevant the interprofessional teamwork and communication learning throughout their future training and clinical experiences. For example, a first-year respiratory therapy student participated in the interprofessional simulation early in the project and stated that he felt too overwhelmed by the pressure to perform the clinical tasks that he has not yet learned. On the basis of this feedback, the simulation designers reviewed the LOs and invited the student to return several weeks later to participate in a similar simulation. The student then reported that he found the simulation engaging and felt motivated to learn more about working in teams.
In our study, the simulation LOs were revised to be more appropriate for prelicensure health care students early in their professional programs. During the process of verifying the assumptions made during simulation development, the researchers became aware that the students reported learning differently than the simulation designers had intended. Both the videos of the student debriefings and the student follow-up telephone interviews highlighted the observation that many of the original LOs were aimed at a higher learning level than was appropriate for first- and second-year students. Therefore, the revised LOs are more relevant for students early in their programs who have minimal previous experience with simulation or interprofessional teamwork. For prelicensure students, debriefing focuses on the appropriate interprofessional skills to provide scaffolding for later learning.
The findings indicated above support the model of interprofessional competencies developed by the authors that describes interprofessional learning on a continuum of exposure–immersion–competence, which also is supported by Bloom’s taxonomy (1956) of LOs. Indeed, the reports of the students in our study support the model, as well as the emphasis on developing the effective exposure level of interprofessional simulation early in health education programs. This is particularly important in IPE learning because negative early experiences can create or propagate stereotypes. Positive exposure to interprofessional teamwork in health education can provide scaffolding for students to later apply the learning about communication and teamwork that they may otherwise have felt was irrelevant.
For stand-alone interprofessional interactions, emphasis should be placed on defining roles, developing respect, developing a culture where asking for help is supported, and teaching communication basics between disciplines. Indeed, the revised LOs in this study reflect the shift from LOs that focus on higher level teamwork and communication skills to those skills that facilitate more exposure-level competencies.
LOs and Debriefing
It is often unclear whether the LOs identified by educators are the same as those practiced and learned by students in the simulation. This disconnect can prevent facilitators from debriefing learning opportunities that are most relevant to the students. In fact, the SBT literature has found that debriefing of the simulations, including receiving feedback and the opportunity for discursive reflection, is the most important feature in effective simulation-based medical education and is responsible for training students in self-assessment and reflection (Issenberg et al., 2005; Stewart et al., 2010). Focusing on intended learning outcomes in a debriefing can help to ensure that the learning that was intended comes to the forefront. This is particularly important in SBT, providing building blocks that enable students to build a foundation of knowledge and skills to support the rest of their curriculum, culminating in the attainment of the professional competencies required at graduation (McGaghie, 1999).
Competency-Based LOs in Interprofessional Simulation Debriefing
It also became clear in our study that using the wording of the original competency statements (Table 1) resulted in higher order LOs that proved challenging for facilitators. For instance, “Demonstrates effective verbal and nonverbal communication for patient safety” was not explicit enough to help facilitators identify specific behaviors in the simulation to discuss in the debriefing. Also, the word “effective” is often difficult to assess in a short simulation, and students have difficulty assessing the “effectiveness” of their communications because they have few team communication experiences from which to make comparison. By contrast, the revised statement shown in Table 1 “Indicates they [the students] knew the roles, expertise, and overlapping scopes of practice of team members (e.g., delegated to or asked for consultation or support from the appropriate professional)” is more specific, and students identified that developing an understanding of their colleagues’ scopes of practice was more relevant learning in this simulation.
The aim of our study was the development of a pragmatic approach to evaluating and revising LOs based on student performance and feedback. The researchers reviewed three occurrences of one simulation, which is a sufficient number for this project, but a greater number of simulation videos may be beneficial for other projects. In situations where reliability in coding is important, such as establishing reliability of a simulation-based clinical examination, it may be of value to have more than two raters code the simulations.
The process of linking LOs to competency statements has demonstrated that a systematic review of the simulation experience and students’ consideration regarding what was learned is necessary to ascertain what is actually being learned. Even carefully designed simulations and debriefings in a competency-based approach may not meet original LOs. Just as the rubric may be used to modify the objectives to fit the simulation, this same process may be used to identify those aspects of the simulation that may need to be modified to fit the LOs.
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Table A: Theories of reflection and Bloom’s taxonomy were examined to inform and guide the development of specific interprofessional education learning objectives (LO) for each part of the simulation. Thus, learning objectives were refined and were specific to the simulation and debriefing phases.
Table A: Theories of reflection and Bloom’s taxonomy were examined to inform and guide the development of specific interprofessional education learning objectives (LO) for each part of the simulation. Thus, learning objectives were refined and were specific to the simulation and debriefing phases.Theories of Reflection (Mann et al., 2007)Bloom’s Taxonomy LevelsSimulationDebriefingFollow UpSimulationDebriefingFollow UpReflection in action:
Reflection on action:
- Insights that occur during simulation (reflective pause)
- Feedback from others during the simulation
- Observational learning through seeing others demonstrate behaviors in the simulation
Reflection on action and in-action (previous reflection integrated with new activities):
- Reflections on simulation (unprompted)
- Reflections on simulation (prompted by the facilitators)
- Reflections on simulation (prompted by the comments or questions of other students)
- Learning skills, techniques, or behaviors from facilitators or other students
For overt behavior:
- Reflections (nonverbal or written)
- Reflections or insights while in practice (comparing the simulation to real work experiences)
- Understand (observe)
Final Revised Learning Objectives for Simulation and Debriefing PhasesSimulationDebriefingFollow Up (No. of quotes from students that apply to this LO)1.1. Indicated they knew the roles, expertise, and overlapping scopes of practice of team members1.1. Opportunity to observe the roles, expertise, and overlapping scopes of practice of all team members1.1. Discussed the roles, expertise, and overlapping scope of practice of all team members271.3. Shows appreciation and respect for each team member (including the patient and family)1.3. Opportunity to gain and show appreciation and respect for each team member1.3. Discussed the contribution of each team member101.10. Practices effective listening techniques (e.g., acknowledges he or she heard the message)1.10. Opportunity to practice effective listening techniques1.10. Discussed effective listening among team members5
Original and Revised Learning Objectives for the Postoperative Teamwork and Communication: Anaphylaxis Simulation
|1. Demonstrates effective verbal and nonverbal communication for patient safety
||1.1. Indicates they [the students] knew the roles, expertise, and overlapping scopes of practice of team members (e.g., delegated to or asked for consultation or support from the appropriate professional)
1.3. Shows appreciation and respect for each team member (including the patient and family; e.g., keeps the patient informed of treatments, answers the patient’s questions, asks for input from other team members)
||1.1. Discusses the roles, expertise, and overlapping scopes of practice of all team members
1.3. Discusses the contribution of each team member
|2. Communicates effectively in transitions of care to ensure the safety of patients
|3. Uses effective written and verbal communication and communication technologies to provide safe patient care
||3.4. Asks for support when needed to provide safe patient care.
||3.4. Discusses the appropriateness of having asked for support or not asked for support
|4. Participates effectively and appropriately in an interprofessional health care team to optimize patient safety
||4.4. Uses structured communication with team members (e.g., SBAR, stated what one is doing aloud to inform other team members, verbal reports were thorough)
||4.4 Discusses what was effective and what was missing in communications among the team members
Learning Objectivesa in the Postoperative Teamwork and Communication: Anaphylaxis Interprofessional Simulation Related to Bloom’s Taxonomy and Stages of Simulation
|Overt Behavior in Simulation
|Nonobservable Events in Simulation
|1.1. Indicates they [the students] know the roles, expertise, and overlapping scope of practice of team members (e.g., delegated to or asked for consultation or support from the appropriate professional)
||1.1. Opportunity to observe the roles, expertise, and overlapping scope of practice of all team members
||1.1. Discusses the roles, expertise, and overlapping scope of practice of all team members
|1.3. Shows appreciation and respect for each team member (including the patient and family; e.g., keeps the patient informed of treatments, answers the patient’s questions, asks for input from other team members)
||1.3. Opportunity to gain and show appreciation and respect for each team member (including the patient and family)
||1.3. Discusses the contribution of each team member
|1.9. Provides and/or accepts feedback
||1.9. Opportunity to provide and accept feedback
||1.9. Provides and accepts feedback
|1.10. Practices effective listening techniques (e.g., acknowledges he or she heard the message)
||1.10. Opportunity to practice effective listening techniques
||1.10. Discusses effective listening among team members
Revising Learning Objectives (LOs) for Interprofessional Education Simulation-Based Learning
|Context: consider the clinical context of the simulation, the level of learner, the disciplines targeted, and the students’ relevant prior learning.
|Step 1. Consider competency statements relevant to your work in interdisciplinary teamwork. Note a range of possible competencies that may be relevant to your simulation. Identify those items that will be the target for your simulation and develop these into LO statements. (Note: keep the omitted competencies for step 4). Design your simulation to meet these LOs. Develop debriefing guides or rubrics to support facilitators in focusing the debriefing on the articulated LOs.
|Step 2. Arrange to pilot your simulation. This may involve establishing collaborations with other programs or institutions. Depending on a myriad organizational factors, it may not be possible to include all of the students or simulation parameters as originally designed. Modify your LO and simulation parameters to accommodate the necessary students or simulation parameters.
|Step 3. Train facilitators in debriefing methods that include the identified LOs but are not limited to them. Facilitators need to be able to identify and facilitate discussion on emergent occurrences that may represent the most important learning opportunity for students.
|Step 4. Pilot your simulation. Keep careful notes about the types of modifications that may be necessary (e.g., if a simulation involving conflict requires a standardized patient to increase his or her level of agitation until a reaction is elicited from the student, note the degree of variation necessary between simulations). Video record simulations and the debriefing of simulations.
|Step 5. Review simulation video recordings and, using the competency worksheet, identify those competency areas that either specifically occurred in the simulation (act) or the opportunity that occurred (potential).
|Step 6. Review the debriefing video recordings and identify those competency areas that are discussed by the students and facilitators. (Note: the content of these discussions can vary according to facilitators’ experiences and adherence to a debriefing guide. For these reasons, some debriefings will be more helpful in confirming the utility of extant LO, whereas other debriefings may be more helpful in confirming the utility of emergent or unconsidered LOs.)
|Step 7. Conduct postsimulation interviews with students. Identify those experiences that students describe as being most relevant to their learning. Make specific note of those experiences that students stated helped them to gain a greater appreciation for the relevance of interdisciplinary teamwork and communication skills.
|Step 8. Complete the competency worksheet from step 5, outlining the learning opportunities at each stage (simulation, debriefing, follow up). Identify the stages that resulted in the most learning.
|Step 9. Revise LOs for simulation and develop a debriefing guide specifically targeting those LOs for the debriefing.