Simulation is a dynamic process affording educators the freedom to create learning activities tailored to meet the needs of their students. Guidelines provided by the National Council of State Boards of Nursing and best practice standards for simulation outlined by the International Nursing Association for Clinical Simulation and Learning (INACSL) provide a strong foundation for the development of simulation programs (Gore & Thomson, 2016). Role-playing via role assignment is a necessary component of simulation; roles are the vehicles that drive the simulation scenario to its desired goals (INACSL Standards Committee, 2016). However, a lack of data identifying best practice for role creation and assignment leaves educators wondering about the most effective approach. The purpose of this article is to present a new strategy for role assignment in simulation that encourages collaboration and prioritization and highlights critical thinking and clinical reasoning.
Background: Role Assignment in Simulation
Traditionally, simulation occurring within nursing education includes assigning students predetermined roles that are typically nursing specific and responsible for particular duties such as documentation, medication administration, procedures, and assessment (Harder, Ross, & Paul, 2013). Designating primary and secondary nurse roles is another common approach in nursing simulation (Weiler & Saleem, 2016). This portioning of duties among multiple participants allows students to divide and conquer, rather than prioritize and delegate. Students often challenge this distribution of nursing tasks among multiple parties, saying it is not a realistic representation of a nurse's workload. However, logistical parameters such as time, space, and available resources necessitate scheduling multiple participants in one simulation scenario (Harder et al., 2013). Research on the effect of role assignment indicates that student benefits from simulation are directly tied to their level of involvement in the simulation experience (Weiler & Saleem, 2017). Students who are assigned roles requiring increased patient involvement display higher levels of critical thinking during the simulation and debriefing process (Weiler & Saleem, 2016). The greater the distribution of nursing-specific duties among multiple students, the increased likelihood of some roles not being as involved and therefore not stimulating as much critical thinking. Ertmer et al. (2010) found that students assigned to the role of the secondary nurse abdicated responsibility in the simulation to individuals selected to be the primary nurse, based on role title alone.
Method: Description of the Two-Heads-Are-Better-Than-One Strategy
The Two-Heads-Are-Better-Than-One (2HeadsR>1) strategy for role assignment in simulation assigns two students to act in the role of one nurse. The students are instructed to move and act as if they are one person; they cannot be in two places at one time, nor can they simultaneously engage in two separate activities. This strategy encourages students to collaborate, prioritize patient care, and delegate as needed. The two students verbalize their clinical reasoning with one another, facilitating the development of a plan of care for the simulated patient. If there is a difference of opinion regarding the appropriate action to take, the students must provide rationale for their plan in an attempt to sway their partner. Ultimately, an agreement is necessary to proceed in their care of the simulated patient. If at any time the two students in the role of the nurse forget the 2HeadsR>1 premise and split apart tending to different patient needs, the simulation facilitator provides a gentle reminder over the intercom that they need to act as one.
The conversation between the two students during the scenario is an example of the Think Aloud (TA) technique—a strategy used in cognitive research, but relatively new to nursing simulation (Burbach, Barnason, & Thompson, 2015). TA is much more than narration of the actions being performed; it is the articulation of the thinking behind the actions (Ericcson & Simon, 1998).
Operationalization of the 2HeadsR>1 strategy has students come to the simulation center in their clinical group with their instructor; there are usually eight students assigned to a 4-hour block of time. The strategy is explained to students as part of the prebriefing session, after which numbers are drawn to determine pairings and sequence. An unfolding simulation scenario, selected to meet the needs and proficiency level of the students, allows students to assume one half of the active participant role for one segment of a four-part scenario.
When students are not in the active participant role, they observe the action via live video streaming from the debriefing room across the hall. The 2HeadsR>1 strategy for role assignment allows individuals watching the scenario to follow the thinking behind the actions and heightens the level of engagement of students in the observer role. Evidence indicates that the observer role affords learners a nonpressured environment to apply critical thinking and analyze the scenario (Hober & Bonnel, 2014; O'Regan, Molloy, Watterson, & Nestel, 2016; Zulkosky, White, Price, & Pretz, 2016). The 2HeadsR>1 strategy also affords clinical faculty members a peek inside the heads of their students, which facilitates the understanding of student thought processes behind the observed actions. Assessment of critical thinking and clinical decision-making skills is possible from a new perspective.
When two students function as one nurse, the more dominant member may unduly influence the course of action, perhaps taking the pair in the wrong direction. If the other student fails to recognize the error in judgment or does not speak up when a misstep is identified, the simulation scenario will proceed accordingly. The simulation facilitator and clinical faculty member monitor the dialogue between the two students and if one student's thinking is leading the pair in the wrong direction, the educators have several options:
- Allow the situation to unfold and let the students experience the consequences of their actions.
- Stop the scenario and explore the students' thinking during a debriefing session.
- Have a simulation educator enter the scenario and effect change by offering cues or by seeking clarification.
Reflective learning during the debriefing will investigate alternate choices and provide time for both students to share their thoughts and feelings regarding the simulation (Mariani, Cantrell, Meakim, Prieto, & Dreifuerst, 2013).
Theoretical Basis for the 2HeadsR>1 Strategy
The idiom 2HeadsR>1 is well-known and its concept that two people working together will outperform either one working independently is generally accepted as true (Bahrami et al., 2010; Brennan & Enns, 2015; Galton, 1907). The seminal research on this theory dates to the early 1900s (Galton, 1907). The 2HeadsR>1 strategy is built on the evidence in support of collaborative cognition. Bahrami et al. (2010) indicated that when two people combine their sensory information, the resulting performance is often better than either individual could execute alone; this is especially true if the individuals engage in open dialogue and express opinions with each other. Collective decision making can surpass that of either individual or collaborative cognition and is enhanced by some degree of diversity among the thinking styles or personalities of the members. Groups that are too similar may be impeded by their lack of perspectives, whereas groups that are too diverse may lack cohesiveness and individual members may find it difficult to communicate with one another (Bahrami & Frith, 2011; Woolley, Aggarwal, & Malone, 2015). When using the 2HeadsR>1 strategy, simulation facilitators should be aware that students who feel comfortable working with each other may, during the simulation, perform at a higher level than would a pair less familiar with one another.
Collaborative cognition relies on open communication and the ability of each participant to accurately assess his or her own competency level. Competency levels among group members should be similar to yield a joint decision that is superior to the one made by any of the members individually (Bahrami et al., 2010). Self-awareness plays a crucial role; if a member overestimates his or her knowledge on the subject or displays overconfidence, the group's decision may be faulty (Bahrami & Frith, 2011). Being right is more important than being confident; the member with the most cogent response will likely prevail more than the more confident, inaccurate member (Trouche, Sander, & Mercier, 2014). Evidence favors the member with the correct thinking more than the one who is more confident and exhibits inaccurate or incorrect thinking; in other words, “truth wins” (Trouche et al., 2014, p. 1958).
Results: Student and Faculty Response to the 2HeadsR>1 Strategy
The 2HeadsR>1 strategy for role assignment in simulation was piloted during the fall 2017 semester; a total of 295 undergraduate students participated in 39 scenario-based simulation activities as part of their clinical rotations in medical–surgical nursing, mental health nursing, pediatric nursing, and transition to practice. The response was overwhelmingly positive; comments on the postsimulation evaluation form indicated that students experienced decreased anxiety and increased confidence because they had a peer at their side. Simulation facilitators reported richer debriefing sessions as a result of knowing when and how the students' clinical reasoning went astray. Discussions between clinical faculty and simulation educators affirmed the decision to continue implementation of the 2HeadsR>1 strategy during the spring 2018 semester, with the addition of community health nursing simulation activities. To date, student encounters with the 2HeadsR>1 strategy total nearly 950 in 119 activities. Actualizing the 2HeadsR>1 strategy is relatively simple and does not require expenditure of additional resources beyond those used with the prevailing method of simulation role assignment. Training requirements for simulation facilitators is minimal and students acclimate to the new approach quickly. Because resource use is unchanged, allocation of additional funding for this new strategy is not necessary.
The 2HeadsR>1 strategy affords clinical faculty members a new perspective for assessing critical thinking skills. Clinical instructors, observing from the control room, follow the scenario and gain insight into a student's decision making. Viewed actions can be linked to verbalized thought processes, revealing levels of clinical reasoning and potential gaps in learning (Burbach et al., 2015). Additionally, the 2HeadsR>1 strategy allows clinical faculty to identify students who need more one-on-one time during clinical hours. Instructors gain valuable insight into their students' clinical reasoning when the 2HeadsR>1 strategy is used and can take the necessary steps to ensure that students are providing safe and effective patient care in the clinical setting.
Assigning two students to operate as one nurse decreases role confusion and empowers both participants to take any nursing action they deem appropriate. Acting alongside a buddy decreases anxiety, which improves learning (Nielsen & Harder, 2013); students appreciate having a peer by their side with whom to discuss options and to explore questions. Prior to the implementation of the 2HeadsR>1 strategy, role confusion often resulted in students standing idle during the simulation scenario. Some expressed frustration when they knew the appropriate actions to take but were not in the role responsible for those interventions. Opportunities to practice teamwork, collaboration, and professionalism abound throughout the simulation activity and mimic the role of nurses working as members of interdisciplinary teams in the clinical setting. TA, fostered by the 2HeadsR>1 strategy, raises students' awareness of the knowledge and abilities they possess, dispelling feelings of inadequacy that they often internalize. Students reported increased confidence after participating in simulation using the 2HeadsR>1 strategy; they reflect on their ability to recognize critical elements, make sound judgment calls, and initiate appropriate interventions in a timely manner.
The 2HeadsR>1 approach allows additional students to be involved as observers and learn from the thinking aloud of their classmates. It is easier to follow the thinking behind the observed actions and evaluate skills such as communication, prioritization, delegation, and situational awareness. Student observers are better prepared to participate in the debriefing session. Research indicates that active observation minimizes stress in the learning process, increases confidence in one's own thinking, and gives students the opportunity to see the bigger picture and appreciate other viewpoints (Hober & Bonnel, 2014).
Conclusion: Implications for Nursing Education and Research
Teachable moments are sometimes missed in the simulation and clinical practice settings when a student performs the right action for the wrong reason. In other words, the instructor may see a student take the appropriate action in a given situation and assume the student understands why he or she performed that act. However, the student may be operating under an assumption based on a previous experience (Dreifuerst, 2015). It is difficult to know how often this will occur, but in every instance, it forfeits a learning opportunity for the students and may also reinforce faulty cognition. TA, initiated by the 2HeadsR>1 strategy for role assignment, exposes inaccurate thinking even when the student provides the proper care. Clinical faculty and sim facilitators recognize the mistaken or misguided thinking and can capitalize on this teachable moment.
The 2HeadsR>1 strategy fosters development of the second Quality and Safety Education for Nurses competency: Teamwork and Collaboration. The two students working as one nurse recognize their own strengths and limitations; they learn the benefits of teamwork and appreciate its positive effect on patient care. The 2HeadsR>1 strategy encourages students to practice different styles of communication while conversing with the patient, a member of the health care team, and one another. Differences of opinion must be explored and ultimately resolved to proceed with patient care (Cronenwett et al., 2007). Repeated exposure to the Quality and Safety Education for Nurses Competency of Teamwork and Collaboration during simulation scenarios employing the 2HeadsR>1 strategy will prepare the students to provide higher quality and safer nursing care upon graduation (Sherwood & Drenkard, 2007).
The creative nature of simulation allows educators to modify existing strategies and generate new ones to meet learning objectives. Adhering to best practice standards ensures quality learning experiences for students. The 2HeadsR>1 strategy for role assignment answers the call for innovative educational methodologies in simulation by creating situational opportunities for students to practice critical thinking, clinical reasoning, and collaboration with peers.
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