The use of simulation continues to increase in prelicensure nursing education and often involves the assignment of different learner roles including the participant and observer (O'Regan, Molloy, Watterson, & Nestel, 2016). Participants make decisions and directly provide patient care during the scenario while observers watch the scenario unfold, commonly from an audiovisual room with synchronous viewing of the scenario, without directly caring for the patient (O'Regan et al., 2016). In fact, during the seminal National Council of State Boards of Nursing National Simulation Study, learners were in observer roles more often than active nurse roles (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). According to recent evidence, observers learn as much as participants (Johnson, 2019; Norman, 2018); therefore, the lack of direct participation in the observer role, which has contributed to assumptions and concerns for educators about the value of the experience for learners, could be mitigated (Bong et al., 2017; Harder, Ross, & Paul, 2013).
These assumptions and concerns stem from an underlying tension between the theoretical foundations for simulation and the assignment of different learner roles (Johnson, 2018; O'Regan et al., 2016). Experiential learning theory (ELT) is commonly identified as underpinning simulation pedagogy (Decker & Dreifuerst, 2012; Dreifuerst, 2009; INACSL Standards Committee, 2016c; Jeffries, Rodgers, & Adamson, 2016; Kolb, 2015; Stocker, Burmester, & Allen, 2014). Inherent in the common understanding of this theory is that learners have to be actively doing something to experience learning. Therefore, there is a concern that the practice of assigning students to observer roles in simulation does not facilitate ELT in its literal definition for learners and that theoretical frameworks or expanded definitions are needed to describe how learning occurs for both participants and observers (Bong et al., 2017; Johnson, 2019; Stocker et al., 2014). Moreover, the increasing use of terminology such as the active participant and passive observer (Bong et al., 2017; Leigh, Miller, & Ardoin, 2017; Norman, 2018) perpetuates the assumptions that observers are missing out on the active, constructivist, experiential learning that simulation offers due to a misunderstanding of both experiential learning and learning occurring through observation and may need to be reconsidered.
Currently, in research and practice in nursing education there is an assumption that observing a simulation is underpinned by the same theoretical frameworks as participating; however, further research is needed to better articulate how these experiences are both active and experiential for the learners. This assumption, without theoretical support, leads to a misnomer that observers are only passively learning during the simulation and that the learning for observers occurs only through debriefing. Furthermore, observational learning is an emerging form of brain-based learning, but it has been theoretically neglected as an aspect of experiential learning (Hoover & Giambatista, 2009; Johnson, 2019). The purpose of this article is to provide an overview of experiential learning (Kolb, 2015), observational learning (Bandura, 1971, 2001), and how recent research and empirical testing support the development of a new framework by merging these two bodies of knowledge together in simulation and debriefing to support both observer and participant roles for learning outcomes.
Experiential Learning in Simulation
Experiential learning is defined as a process whereby knowledge results through the transformation of an experience (Kolb, 2015). ELT involves two major constructs, including grasping and transforming an experience and four major concepts including the concrete experience, reflective observation, abstract conceptualization, and active experimentation (Kolb, 2015) (Figure 1). Much of the literature in simulation focuses on guiding learners through the four different concepts, whereas minimal focus is placed on the two major constructs of grasping and transforming experiences. The grasping of an experience involves taking in an immediately sensed concrete experience with minimal analysis or inquiry. The grasp is further solidified into learning through abstract conceptualization where order is introduced into the seamless flow of the concrete experience through communication, prediction, and/or recreation of it (Kolb, 2015). The grasped experience is then transformed through internal reflective observation—or looking back—on an experience. Then, through extension of knowledge by active experimentation, learners test knowledge in a new situation that is similar on the surface but different in deep structure (Dreifuerst, 2009; Forneris & Fey, 2016; Kolb, 2015; Schön, 1983). By creating tension between grasping and transforming knowledge, assimilation (or knowledge consistent with previous frames) and accommodation (or knowledge opposed to existing frames) are supported outcomes of the theoretical framework (Kolb, 2015; Piaget, 1952). Assimilation and accommodation are components of judgment, reasoning, and metacognitive thinking, the distinguishing factors of the expert nurse (Benner, Stannard, & Hooper, 1996). Assimilation and accommodation are also considered the ultimate goals of a practice profession (Dreifuerst, 2009).
Structural dimensions underlying the process of experiential learning and the resulting basic knowledge forms. From Experiential Learning: Experience as the Source of Learning and Development (2nd ed.), by D.A. Kolb, 2015, New York, NY: Pearson Education, Inc. Copyright 2015 by Pearson Education, Inc. Reprinted with permission.
Debriefing facilitates the transformation of the experience and fosters the development of assimilation and accommodation in both participants and observers (Dreifuerst, 2009; Johnson, 2019), yet, confusion continues regarding how learners in observer roles grasp the concrete experience. Bong et al. (2017) suggested that the concrete experience in ELT is missing for students in observer roles, whereas Norman (2018) noted that the concrete experience is participated in by observation. Kolb (2015) never explicitly stated that concrete experiences in ELT cannot be observational in nature (Hoover & Giambatista, 2009). Moreover, O'Regan et al. (2016) articulated that it is dangerous to think that a concrete experience requires hands-on participation. Rather, because the concrete experience is instantaneous and requires no analysis or inquiry (Kolb, 2015), it is sometimes considered problematic for learners who are observing because there is concern that observers are not grasping as much as those who are immersed in the simulation and therefore passively learning from the simulation (Johnson, 2018).
Social Learning Theory and Social Cognitive Theory
Three recent empirical studies in nursing examined participant and observer roles using a theory directly applicable to observational learning (Bong et al., 2017; Livsey & Lavender-Stott, 2015; Rode, Callihan, & Barnes, 2016). In these studies, social learning theory (SLT) was used as the guiding framework. Social learning—also described as observational learning, vicarious learning, visual learning, mimicry, or imitation— has received a large amount of theoretical attention outside of nursing. Observational learning is a process where a learner reproduces overt behavior that has been previously modeled (Bandura, 1971). Bandura (1971) described four concepts within observational learning: attention, retention, motor learning, and motivation. If the learner is attentive and motivated to learn, symbolic representations, or codes, assist in developing imaginal and verbal retention processes. These symbolic codes are available for knowledge retention and lead to behavior reproduction. Additionally, Bandura (2001, 2005) built on the cognitive aspect of observational learning and suggested that through cognitive ideas, observed behavior, and feedback for error correction, an individual can translate knowledge into performance. Therefore, in social cognitive theory (SCT), even covert reasoning and decision making become observable, and action and errors are not required for learning when verbal modeling and thinking aloud are used (Bandura, 2005; Meichenbaum, 1984).
Using current technology, neurophysiological evidence has shown that learning occurs when observing. The current generation of learners is surrounded by a world full of visual experiences, including gaming and virtual worlds. It is estimated that the average young adult spends nearly 10,000 hours gaming by age 21 (McGonigal, 2011). According to Kühn and Gallinat (2014), this amount of lifetime gaming results in structural changes in the hippocampal, parietal, and occipital brain regions that correlate with advanced visual capabilities, including visuospatial expertise and enhanced visual attention as opposed to people who do not game (p. 845). One area of the brain, the mirror neuron system, mediates imitation and transforms observed actions into knowledge by activating the action-observation network of neurons, which is known to have a role in understanding the intention and “code the ‘why’” (Iacoboni et al., 2005, p. e79) and meaning of actions for future reproduction (Caggiano et al., 2012; Iacoboni et al., 2005; Rizzolatti, Ferrari, Rozzi, & Fogassi, 2006).
Within this complex network of neurons, humans begin processing the understanding and execution of actions, emotions, speech, and intentions, all through observation. Moreover, Cross, Kraemer, Hamilton, Kelley, and Grafton (2009) reported that the action-observation network has similar neurological representations, which are constructed when an individual both observes or physically practices an action. Schiffer, Ahlheim, Wurm, and Schubotz (2012) noted that the hippocampus and cerebellum are primary brain structures involved in taking prior knowledge to then sequentially assimilate and accommodate the information. Hippocampal activity decrease is understood as a learning hallmark, and when a difference is presented to a priori knowledge, hippocampal activity increases and informs the brain to accommodate the information. Hippocampal activity increases when accommodating and decreases when assimilating information (Schiffer et al., 2012), and the role of the cerebellum is to primarily assist in accommodating new information when the learner recognizes and attempts to control for errors and activates similarly when learning through observation (Callan et al., 2013; Monfardini et al., 2013). This literature provides reasonable support that through observing an experience, the ability to grasp the concrete experience is made possible and different areas of the brain activate in response to both the desire to imitate behavior and to control for errors.
Observational Experiential Learning in Simulation
Given the strong underpinning of simulation with ELT, the concern regarding whether learners in different roles experience all facets of ELT and that social or vicarious learning and ELT form a basis for observation (Delisle et al., 2019; O'Regan et al., 2016) result in the need for a new theoretical model (Johnson, 2018). Kolb (2015) described the concrete experience as requiring minimal analysis or inquiry. However, participants and observers have different concrete experiences. Although participants are immersed in decision making in the scenario, observers are in a viewing role with different immediate sensations, one that is assumed to be active and observed with close attention. Therefore, vicarious experiential learning explains how both observation and hands-on learners result in significant and meaningful learning. Hoover and Giambatista (2009) first described vicarious experiential learning as an educational methodology that:
exists when a personally responsible participant(s) cognitively, emotionally, and behaviorally processes knowledge, skills, and/or attitudes through processes of observation in a learning situation characterized by a high level of active involvement despite absence of direct, personalized consequences.
Vicarious, (“Vicarious,” n.d.) implying a passive experience, is in contrast to observing (“Observing,” n.d.), where there is careful noticing with attention and when used in simulation can be called observational experiential learning (OEL). This framework (Figure 2) was adapted from ELT concepts (A. Kolb, personal communication, June 8, 2018) and diagrammed to explicate concepts from both SLT and SCT within clinical situations (Johnson, 2019). This framework was tested with simulation using Debriefing for Meaningful Learning© (DML), an evidence-based method of debriefing that is theoretically derived from several learning theories including ELT (Dreifuerst, 2012; Johnson, 2019) (Figure 2).
Observational Experiential Learning© (OEL) Framework (Johnson, 2018). Dashed horizontal line indicates the grasp of an experience; bulleted vertical line indicates transformation; Debriefing for Meaningful Learning® (DML) is represented by the center circle.
The four ELT concepts (light gray circles) are a reiteration of ELT (Figure 2), with no changes to the original framework (Kolb, 2015). The grasp of an experience is described as the learning that occurs during the simulation scenario. The concrete experience is the immediate sensation of learning requiring no analysis or inquiry, and the abstract conceptualization is the ability to describe the concrete experience by verbally recreating the experience during debriefing (Kolb, 2015). The transformation is attributed to debriefing in simulation, where learners are guided through reflective observation and then begin thinking about how the knowledge is applied in future situations in active experimentation (Decker & Dreifuerst, 2012; Dreifuerst, 2009; Forneris & Fey, 2016; INACSL Standards Committee, 2016a). Reflective observation is the internal reflection on the previous concrete experience where ascribing meaning to an experience begins, and active experimentation is the final stage of ELT where learners test or apply prior experiences in a new situation, completing the transformation of the experience (Kolb, 2015). This is achieved by presenting a reflection-beyond-action parallel case in DML that is similar to the previous experience but contains subtle differences (Dreifuerst, 2012, 2015). The two most important elementary forms of knowledge—assimilation and accommodation—are outcomes of the experiential learning cycle, which is facilitated by tension between the different forms of grasping and transforming of an experience (Kolb, 2015). Assimilation and accommodation are goals of a practice profession and linked to reflection (Dreifuerst, 2009).
Attention, motivation, motor reproduction, and knowledge retention (Figure 2) describe Bandura's (1971) SLT for observational learning. Two antecedents are also depicted in Figure 2: attention and motivation. Attention is more than simple exposure to modeling of behavior; rather, attention is the concernful noticing of behavior, whereas motivation is driven by human agency rather than positive reward (Bandura, 1971, 2005). Human agency consists of intentionality, fore-thought or anticipation, self-reactiveness and regulation, and self-reflection. A human agent plans intentionally, anticipates an action plan, and executes that action plan, followed by self-reflection (Bandura, 2001). Considering that the concrete experience requires no analysis or inquiry (Kolb, 2015), it is assumed that those learners who are observing the simulation are immersed in the actual experience; however, they simply may be watching with little attention or intention for reproduction (O'Regan et al., 2016). Nevertheless, the observer must be cued and engaged to inform the attention, intention, and action planning of the concrete experience for future transformation. Therefore, this experience in OEL is more than passively watching an event or exposure to a situation with little analysis or inquiry. Rather, it is a deeper, more informed concrete experience that engages the observer's attention and intention to motivate future behavior and knowledge reproduction.
The final two concepts in SLT are the outcomes of the framework: retention and motor reproduction. Retention processes involve the memory of an experience or behavior over a period of time, and observed behavior must be evaluated and reproduced to assess for the skillful mastery of observational learning (Bandura, 1971). These concepts, found at the ends of both poles of OEL, indicate that learning occurs through the grasped scenario, noted by the dashed horizontal line (Figure 2), and through the transformation of debriefing, noted by the bulleted vertical line (Figure 2).
Finally, the center circle (Figure 2) merges the two bodies of knowledge bringing simulation and OEL together. Although experiential learning is commonly assumed to occur only when learners are in direct experience (Bong et al., 2017; O'Regan et al., 2016), Kolb (2015) asserted that experiential learning occurs by creating tension between grasped and transformed experiences. Therefore, the central circle demonstrates that it is the tension and interaction between all four concepts that draw out experiential learning, resulting in the development of elementary forms of knowledge, including assimilation and accommodation (Dreifuerst, 2009, 2012; Hoover & Giambatista, 2009; Kolb, 2015).
Further, to bridge simulation as a teaching and learning pedagogy grounded in ELT and OEL, DML is represented by the center circle. DML is underpinned with ELT to foster the development of assimilation and accommodation for clinical reasoning. Additionally, through reflection-beyond-action, anticipation and forethought are fostered as concepts of human agency (Dreifuerst, 2009, 2012; Johnson, 2018) to develop reasoning and higher order thinking. Through DML's structured, yet iterative, process of guided reflection and abstract conceptualization using “what-if” Socratic questioning, the assimilative knowledge develops (Dreifuerst, 2015). DML ends with the presentation of a parallel case that requires anticipation in addition to assimilation and accommodation in the reflection-beyond-action component of DML facilitating accommodative knowledge, the final stage of ELT (Dreifuerst, 2015; Johnson, 2019).
OEL was tested by evaluating knowledge of the grasped clinical scenario before debriefing, the transformed experience after debriefing, and as applied (assimilated/accommodated) to a similar case of respiratory distress containing nuances in clinical care to examine learning in active participant versus observer roles (Johnson, 2019). This was important because it allowed for the ability to discern the learning that occurs from observation (Johnson, 2019). This work added to the growing body of knowledge in nursing literature that there are no differences in cognitive knowledge outcomes between participants and observers in simulations (Norman, 2018; Rode et al., 2016; Rogers, Andler, O'Brien, & van Schaik, 2019; Scherer, Foltz-Ramos, Fabry, & Chao, 2016).
In an experimental, pretest–multiple posttest repeated-measures study, Johnson (2019) articulated that there were no significant differences in knowledge scores between participant and observer roles before debriefing, after debriefing, or 4 weeks later (n = 119, p = .773). There was also no significant difference between participant and observer (n = 119, p = .459) when applying the knowledge to a similar situation (Johnson, 2019). Therefore, OEL was operationalized as the simulation scenario facilitated the grasping of the experience, the debriefing facilitated the transformation of the experience, and there was no difference in cognitive knowledge gain, retention, and application between participants and observers.
Implications for Simulation Educators
Observers and participants both grasp and transform experiences in simulation and debriefing (Table 1). However, a concrete experience is a tangible and immediately felt experience requiring minimal analysis or inquiry (Kolb, 2015), and exposure does not mean that a learner is intentionally attentive or motivated to learn (Chaffee & Schleuder, 1986). Therefore, both attention and motivation are described in OEL as antecedents to optimize these grasped experiences resulting in significant and meaningful learning for both participants and observers. Attention involves intentional observation and engagement with goal setting, a desire to solve complex situations, and is in contrast to passive watching (Bandura, 1971; Johnson, 2018; McGonigal, 2011; O'Regan et al., 2016). Motivation involves human agency, a commitment to bring about a future action that is driven by intention, anticipation, self-reactiveness, and self-reflectiveness (Bandura, 2001).
Experiential Learning Theory and Simulation
Tools, checklists, or worksheets are commonly used to optimize observer roles in simulation (Bethards, 2014; O'Regan et al., 2016). According to O'Regan et al. (2016), there is a high association between learning outcomes and observer tools; however, educators should be cautioned that the addition of a worksheet as a means of creating attention and engagement is not always necessary. Ritchhart, Church, and Morrison (2011) stated:
Many teachers feel they have to have [worksheets]. Perhaps it is due to the fact that schools have for such a long time focused on learning as work and not trusted students to do that work…caus[ing] teachers to want something tangible that they can look at to see whether learning has happened.
Although worksheets may be useful and appropriate at times, educators should carefully consider their use and potential overuse and that they may actually deter the attention of the observer from the experience instead of engaging them in it. Rather, educators should consider integrating engaging practices such as narrative pedagogical approaches or virtual reality telepresence into teaching and learning. Narrative pedagogy practices include creating an invitation to learn, questioning to teach thinking, and co-creating experiences with both the teacher/facilitator and learner to learn with each other (Diekelmann & Diekelmann, 2009; Ironside, 2004, 2014). Virtual reality telepresence is another way of increasing observer attention, engagement, and a feeling of being immersed in a simulation scenario (Dang, Palicte, Valdez, & O'Leary-Kelley, 2018).
There are many threats that can limit learner engagement or attention and weaken the experiential learning process, as well as the future motivation to learn in simulation that a worksheet alone will not solve (Rudolph, Raemer, & Simon, 2014). These include a lack of buy-in to simulation, problematic fidelity, a feeling of professional identity exposure, and defensive feelings when discussing substandard performance (Rudolph et al., 2014). An ideal place to cultivate intentional attention and the agentic perspective of motivation (intention, anticipation/forethought, self-reflectiveness, self-reactiveness) (Bandura, 2005) is in the prebrief by establishing a safe container (Rudolph et al., 2014), which is a confidential environment that engages all learners, sets high standards, and sets the stage for meaningful challenges without intimidation, humiliation, or retribution (Delisle et al., 2019; O'Regan et al., 2016; Rudolph et al., 2014; Rutherford-Hemming, Lioce, & Breymier, 2019). During the prebrief, educators can also begin enabling narrative pedagogical practices to transform simulation.
The prebrief is a time before the scenario for focused preparation regarding their objectives and role (INACSL Standards Committee, 2016b, 2016c). Page-Cutrara (2015) expanded on the INACSL definition and discussed prebriefing as a time when information and activities prior to the simulation are:
Provided to learners in consideration of their level of knowledge, learning needs, and prior experiences; structured for anticipatory reflection and planning; and facilitated by qualified nursing simulation educator to support decision-making, psychological safety, and debriefing activities
Page-Cutrara (2015) described outcomes of prebriefing including engagement and readiness of the learner. Therefore, the prebrief is focused on increasing attention and motivation of the learner to learn as opposed to fostering passive watching. By creating an environment with psychological safety for learners to make mistakes and using narrative pedagogical practices such as creating invitations to learn, both observers and participants are invited to take risks with new thinking and action (Ironside, 2014; Rudolph, Simon, Dufresne, & Raemer, 2006).
This framework is foundational to testing evidence-based observational protocols that support and facilitate brain-based learning. An abundance of literature in neuroscience that is also emerging within simulation research provides evidence that observers grasp an experience differently, yet perform similarly when compared with those who behaviorally participate (Andrieux & Proteau, 2013, 2014; Domuracki, Wong, Olivieri, & Grierson, 2015; St-Onge et al., 2013; Welsher et al., 2018). These different methods include self-observation, novice/flawed observation, expert/flawless observation, mental imagery, mixed observation, and feed-forward.
Self-observation and observing another individual making errors are known to activate the cerebellum for the future control of errors (Andrieux & Proteau, 2013, 2014; Callan et al., 2013; Domuracki et al., 2015). Observing a novice performer is similar to self-observation because it enhances the ability to correct for errors, but alone may still result in inconsistent outcomes (Andrieux & Proteau, 2013). In a study regarding central line insertion with medical students, the observation of a novice showed improved performance; however, this was evident only when feedback was provided to the learner as specific errors occurred (Domuracki et al., 2015). It is important to remember that when novice learners observe other novices execute clinical practice, there could be inconsistent results compared with observing an expert, given that observed mistakes may subsequently be modeled.
The mirror neuron system and the action observation network are activated during the observation of an expert performance; therefore, this is a more proficient method to retain and apply knowledge (Andrieux & Proteau, 2013; Callan et al., 2013). The observation of an expert contributes to the intent to imitate and understand the underlying actions resulting in a successful performance (Andrieux & Proteau, 2014; Callan et al., 2013). Expert role modeling is not new to the simulation and nursing literature (Kardong-Edgren et al., 2015); however, further exploration as to how it assists in the optimal grasping of an experience is warranted given that mental or motor imagery, or the internal rehearsal of previously observed and performed actions, unifies higher level cognition with lower level motor behavior (Bach, Allami, Tucker, & Ellis, 2014). Both observing an action and motor imagery activate the mirror neuron system and contribute to the improved execution of strong cognitive tasks, compared with motor behavior alone (Bach et al., 2014; Gatti et al., 2013). Through the use of mental rehearsal, an observational learner has the ability simulate their plan of action, even repeatedly with refinement (Hoover & Giambatista, 2009; Hoover, Giambatista, & Belkin, 2012).
Finally, according to Andrieux and Proteau (2013, 2014), a mixed-observation protocol where the observer viewed both a novice and expert demonstration produced the most similar outcomes, compared with a group physically practicing skills. A mixed protocol allows for both the intent to imitate and intent to reduce errors (Andrieux & Proteau, 2013, 2014). In fact, the mixed-observation group outcomes significantly outperformed groups that only observed experts (Andrieux & Proteau, 2013, 2014). Mixed-observation protocols allow learners to grasp an experience with the intention of understanding both the flawed demonstration and expert demonstration that would be available for transformation—thus, facilitating OEL because observing an expert in tandem with observing a novice allows for both assimilation and accommodation of different performances, thereby informing future execution. When mixed observation is combined with feedforward, or letting learners know what they are about to observe, brain patterns activate to recognize for errors and imitate experts (Andrieux & Proteau, 2016). Feedforward could be incorporated into prebriefing as a place to cue for anticipation and then discussed further in debriefing to recall differences in performances. Medical research measuring these concepts during skill performance are informative (Domuracki et al., 2015; Welsher et al., 2018); however, more are needed in nursing simulation to identify optimal grasping of experiences and transformation through debriefing with high-quality, theoretically derived and evidence-based debriefing, such as DML.
ELT is a common theoretical foundation for simulation in nursing; yet, further theoretical support for the value of the observer role is warranted. OEL is one body of work that uses ELT to describe how the observer learns differently than the participant yet just as relevantly, merging the work of both Kolb and Bandura to describe both grasped experiences and transformed experiences. Grasped experiences can be optimized through evidence-based pedagogical practices that are incorporated into the prebrief and simulation scenario design. These brain-based observational protocols are just coming to the forefront and remain in need of further testing to grow this area of nursing education science.
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Experiential Learning Theory and Simulation
|ELT Concept (Construct of Knowledge)||Simulation Practices|
|Concrete experience (Grasping)||Participating or observing a simulation. Incorporating brain-based observation protocols. Using OEL to optimize the grasp.|
|Reflective observation (Transforming)||Debriefing: Reflection-in-action and reflection-on-action. Analyzing the experience (Dreifuerst, 2009; Schön, 1983).|
|Abstract conceptualization (Grasping)||Debriefing: Elaborating on and recalling the experience using Socratic questioning (Dreifuerst, 2009, 2012).|
|Active experimentation (Transforming)||Debriefing: Reflection-beyond-action/anticipation, applying knowledge to a situation that is similar to a previous one with some similarities and differences (Dreifuerst, 2009, 2012; Forneris & Fey, 2016; INACSL Standards Committee, 2016a, 2016b, 2016c).|