Nurse Education Today 35 (2015) e8–e13
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The simulation method in learning interpersonal communication competence—Experiences of masters' degree students of health sciences Terhi Saaranen a,⁎, Anne Vaajoki a, Marjaana Kellomäki b, Marja-Leena Hyvärinen c a b c
University of Eastern Finland, Faculty of Health Sciences, Kuopio Campus, Department of Nursing Science, P.O.B 1627, 70211 Kuopio, Finland Kuopio University Hospital, Development, Clinical Education and Research Unit of Nursing, P.O.B 100, 70029 KYS, Finland University of Eastern Finland, Kuopio Campus, Language Centre, P.O.B 1627, 70211 Kuopio, Finland
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Article history: Accepted 16 December 2014 Keywords: Simulation Nursing science Interpersonal communication Competence Education
s u m m a r y Background: This article describes the experiences of master students of nursing science in learning interpersonal communication competence through the simulation method. The exercises reflected challenging interactive situations in the field of health care. Few studies have been published on using the simulation method in the communication education of teachers, managers, and experts in this field. Objectives: The aim of this study is to produce information which can be utilised in developing the simulation method to promote the interpersonal communication competence of master-level students of health sciences. Design: This study used the qualitative, descriptive research method. Settings: At the Department of Nursing Science, the University of Eastern Finland, students major in nursing science specialise in nursing leadership and management, preventive nursing science, or nurse teacher education. Participants: Students from all three specialties taking the Challenging Situations in Speech Communication course participated (n = 47). Methods: Essays on meaningful learning experiences collected using the critical incident technique, underwent content analysis. Results: Planning of teaching, carrying out different stages of the simulation exercise, participant roles, and students' personal factors were central to learning interpersonal communication competence. Conclusion: Simulation is a valuable method in developing the interpersonal communication competence of students of health sciences at the masters' level. The methods used in the simulation teaching of emergency care are not necessarily applicable as such to communication education. The role of teacher is essential to supervising students' learning in simulation exercises. In the future, it is important to construct questions that help students to reflect specifically on communication. © 2014 Elsevier Ltd. All rights reserved.
Introduction Expectations are high regarding the interpersonal communication competence of health care professionals. They are expected to be able to adapt themselves to constantly changing situations and interactive relationships, e.g., in different negotiation, group, and conflict situations (Myers et al., 2011). Such competence is a central component of the expertise of health care personnel (Ministry of Education, 2006; Finnish Patient Safety Strategy, 2009–2013, 2009; Health Care Act, 1326/2010, 2010). It has been indicated that, e.g., well-functioning interpersonal communication promotes collaboration within and between work groups (Brindley and Reynolds, 2011). Therefore, masters' level education in this field must prepare students for challenging interpersonal situations and ⁎ Corresponding author. Tel.: +358 500 940 242. E-mail addresses: terhi.saaranen@uef.fi (T. Saaranen), anne.vaajoki@uef.fi (A. Vaajoki), marjaana.kellomaki@kuh.fi (M. Kellomäki), marja-leena.hyvarinen@uef.fi (M.-L. Hyvärinen).
http://dx.doi.org/10.1016/j.nedt.2014.12.012 0260-6917/© 2014 Elsevier Ltd. All rights reserved.
provide them with interactive skills required by their future work positions. Interpersonal communication occurs in relationships between individuals as a result of cooperation between different parties (Spitzberg and Cupach, 2011). Competence in it is formed by cognitive, skill-related and affective aspects. The cognitive aspect contains the idea that the communicator knows and understands what effective interpersonal communication requires and what is expected from it. The skill-related aspect refers to displaying appropriate, effective and functional behaviour in any given situation and interpersonal communication relationship. The affective aspect includes the motivation, feelings and attitudes of participants. Interpersonal communication competence is constructed by the cooperation of the different participants in interaction and it is closely related to the topics of respecting others, tolerating differences and being ready for personal development (Spitzberg and Cupach, 2011). In the development of interpersonal communication competence, the simulation has been found to be an effective and useful method
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that fosters reflective learning (Brindley and Reynolds, 2011). Simulation imitates real-life situations and makes genuine phenomena and processes visible in fictional conditions (see Bambini et al., 2009). In the field of health care, simulation learning has proved to be an effective pedagogical method which develops not only clinical abilities but also interactive competence in different “real” health care settings (see e.g., Berragan, 2011). However, research on the topic has thus far concentrated either on examining the use of this method in clinical training (e.g., Bambini et al., 2009) or applying simulations in expert– client interactions (Koponen et al., 2012). Few studies have been published on the use of simulation in the context of interpersonal communication training of health care teachers, managers and experts, which is the focus of this study. Background Literature Research has indicated that simulation exercises improve students' interpersonal communication skills (Moule et al., 2008; Zavertnik et al., 2010; Pearson and Mc Lafferty, 2011), cooperative skills, and interaction occurring between different professional groups (Berg et al., 2010; Reese et al., 2010; Brindley and Reynolds, 2011; Pearson and Mc Lafferty, 2011; Reising et al., 2011; Wagner et al., 2011). There is also evidence that simulations enable increasing students' interest in the topic of interpersonal communication competence (Berg et al., 2010; Bosse et al., 2010; Koponen et al., 2012) and increase their professional confidence and trust in their own skills (Rosenzweig et al., 2008; Bambini et al., 2009; Kameg et al., 2010; Pike and O'Donnell, 2010). Students consider simulation to be an interesting, enjoyable and useful learning method (Kameg et al., 2010; Pearson and Mc Lafferty, 2011). As a learning process, the simulation method combines several different learning theories. It may include features of cognitive, social, realistic, constructive and experiential learning. According to cognitive learning theory, students utilise their previously acquired knowledge in a simulation learning situation and actively reflect on what happened in the situation, what was learned from it and what could have been done differently. From the perspective of social learning theory, simulation learning occurs in social interactive situations among students by observing others' working, their competence and behaviour (Rutherford-Hemming, 2012). According to realistic learning theory, students' perceptions related to their knowledge, skills and attitudes based on reality are highlighted in simulation learning. Moreover, constructive learning theory emphasises that learning occurs through active, experiential and social collaboration (RutherfordHemming, 2012). Simulation learning is also strongly connected to Kolb's (1984) experiential learning theory. The experiential learning cycle can be divided into four separate stages in which all steps are closely interconnected, forming a learning cycle. Learning is founded on a learners' subjective and personal experience related to an encountered topic or experience and connected activities. The learner simultaneously reviews and reflects on different aspects of the subject and thus builds new understanding of applications or changes in operations. During the subsequent conceptualisation stage, the learners' aim at modifying their previously acquired knowledge and creating new operational models and theories, after which the newly learned subject can be applied as a practical solution. (Dieckmann et al., 2009). In order to facilitate a successful and effective learning process, the teachers' ability to give instructions, guide the simulation and give feedback is significant (Wotton et al., 2010; Shinnick et al., 2011; Kable et al., 2013). Accordingly, debriefings, in which students have the opportunity to process the topics learned, combine topics with previously acquired knowledge and consider how this could be utilised in the future, form a particularly crucial stage. In sum, a simulation is an event in which interactive learning occurs through doing, experiencing, feeling and reflecting (Bambini et al., 2009; Dreifuerst, 2012).
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Aim In this study, the simulation method was applied in the communication training of teachers, managers, and experts in the field of health care. The aim was to examine what factors are important in students' learning of interpersonal communication competence using the simulation method. Methods Setting The Challenging Situations in Speech Communication course (1 credit point) was held in 2012, including simulation exercises that lasted two days. The simulation exercises were chosen to support the learning objectives of the course, viz., to strengthen students' understanding of the importance of interpersonal communication competence and the core skills needed in health care professions. Before the simulation exercises, there were lectures on communication, and simulation as a learning method. The simulation method was adapted from emergency care simulation training which is well known and widely used in health care. All students had two scenarios in simulation exercises founded on real-life events: a challenging negotiation at a hospital ward (scenario 1) and evaluation discussion between a student, teacher, and staff, towards the end of the practical training period (scenario 2). The simulation exercises were conducted in a simulation room, guided by both the speech communication and nursing science teachers working as pairs. The simulation exercises were performed in three different groups. Each group had approximately 20 students. From these students four to six were actors in each scenario, and the rest (n = 15) were observers. The simulation exercises involved three phases: the prebriefing, the simulated practice scenario, and the debriefing (Rhodes and Curran, 2005; see also Page-Cutrara, 2014). At first, teachers carried out a prebriefing, i.e., an orientation for the entire group. Next, volunteer students were asked to act in predetermined roles in the scenario, not as themselves. One of the teachers instructed the actors before the beginning of the scenario. Simultaneously, another teacher gave instructions to the rest of the students on making observations of the scenario. They were asked to observe what kinds of actions should be repeated and what should not. In summary, the simulation exercise included a prebriefing (60 min) and the scenario itself (15 min), during which teachers instructed the students functioning in the roles via a microphone. After the scenario, the entire student group gathered to participate in a shared debriefing guided by the teachers (45–60 min). The scenario was documented on video and the recording was utilised in the debriefing. Data Collection This study used the qualitative research method. The data were collected using the critical incident technique in the form of essays, which made it possible to acquire multifaceted and profound information on the phenomenon studied (Schluter et al., 2008; Vachon and LeBlanc, 2011). In these essays, students were instructed to describe one positive and one negative learning experience from the simulation exercises. Subsequently, students were asked to select one of the experiences for further analysis; to scrutinise how the positive or negative learning experience that they had chosen had attained significance. Furthermore, the students were instructed to reflect their experience on their reading of literature and to consider how they could exploit what they had learned in their future work as preventive nursing experts, nursing managers or health science teachers. The students were encouraged to write about their learning experiences immediately or within two weeks after the latest simulation exercise.
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Altogether 58 students in three different groups took part in the course. From these students, 50 students consented to the use of learning assignments in the study, and three essays were rejected, because they did not deal with the students' experiences of the simulation exercises. Altogether 47 essays were included in the final analysis (response rate 81%). There were 154 pages of written material consisting of students' essays.
on the critical incident method was a mandatory part of the course, but submitting an essay for the study was voluntary. The students were informed both orally and in writing that the learning assignment was to be handled with confidentiality and anonymously throughout the entire study and that all personal data would be removed and could not be divulged during any stage of research. Students were also informed that the essays were not to be published as such anywhere. Subsequently, students submitted their written consent to participate in the research.
Data Analysis The essays underwent inductive content analysis (Elo and Kyngäs, 2007; Polit and Beck, 2012). First, to get a general view, the data were read carefully several times. Second, in order to make sense of the data as a whole, the units of analysis were selected. An individual sentence or several words or sentences which together had unified a concept made up one unit. At this stage, the data were classified and subcategories were formed. Each subcategory was labelled using words denoting content-characteristics. Thereafter, all the subcategories were combined into four high-level categories, which were also based on the content. Finally, the main category was identified and named factors connected to learning interpersonal communication competence through the simulation method (see Fig. 1). While the analysis itself was conducted by one researcher, the different stages of analysis were processed and developed in cooperation with the research group in different stages. Ethical Considerations The entire research was performed according to the ethical principles presented in the guidelines of Responsible conduct of research and procedures for handling allegations of misconduct in Finland (Guidelines of the Finnish Advisory Board on Research Integrity, 2012). Writing an essay
Results Based on the data, the main category of factors connected to learning interpersonal communication competence through the simulation method included four high-level categories: planning of teaching, carrying out the different stages of the simulation exercise, participant roles, and students' personal factors. As shown in Fig. 1, every high-level category was formed by combining different subcategories. According to the students' essays, planning of teaching helped to build a foundation for learning. The connection between aims and their realisation, the planning of scenarios, the size and timetable of the group, and considering study orientation emerged as central themes in the essays. When considering the connection between aims and their realisation, students expected the activities to be constantly consistent with the aims of the course. Some of the students felt that the aims had been reached, while others found that the simulation exercises had not entirely corresponded with the goals set for them. This view emerged particularly in connection with the debriefings, in which there was some digression from the course aims. Students found the scenarios, dealt with already familiar topics, to be appropriate, realistic, and educational. They were also able to connect
Fig. 1. Factors connected to learning interpersonal communication competence through the simulation method.
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the topics to their experiences from working life or to consider the usefulness of what they had learned in their future work positions. “For me, a positive experience emerging from the first simulation event was that in its similarity, the entire presentation situation strongly reminded me of my workplace's…meetings” “…you learned a lot about the simulation situations and the learning method in question fit the classes and was rewarding” Some of the students found the timetable of the simulation day overtly strict or the group sizes too big. “The simulation day should be longer or the groups smaller so that everyone could participate.” Considering students' different orientation studies (nursing management and leadership, preventive nursing science and nurse teacher education) was also deemed important. Students highlighted the view that the scenarios should be relevant regardless of the study orientation. The students felt that they had learned from all of the different stages of the simulation exercise: the prebriefing, the simulated practice scenario and the debriefing. A clear introduction to the topic was provided during the prebriefing as the simulation was a new experience for some of the students. The students were pleased with the fact that they were told about the simulation methods and informed about what they could learn from the simulation exercises before the simulation occurred. “As the day began, we were told that the situations that we were going to portray were connected to concrete circumstances that anyone of us could come across in the working life. This felt good and inspired us…” When carrying out a simulated practice scenario, students valued the atmosphere, the length of the exercise and getting guidance from teachers in the situation. A number of students felt that the amount of guidance they had received was satisfactory. They found that it was better that they got to think for themselves, e.g., on how to proceed with their roles as actors in a scenario. Conversely, others found the amount of guidance inadequate, which caused a sense of insecurity in them. The responses on the topic of the debriefing highlighted the importance of reflection, the challenges related to taking the roles apart, and watching the video recordings of the scenarios. The students found that the discussions had dealt with the contents of interpersonal communication competence in a versatile way. Students experienced the discussions as fruitful and constructive, and the time reserved for it was perceived as sufficient. Moreover, guidance received from teachers was considered important although some felt that they needed more of it. Some of the students considered that watching the video recordings had been educational, while others considered this futile or even saw it as a source of anxiety. The participant roles in the simulation exercises were comprised of actors and observers. The students described that they had been able to learn from both roles. Some considered it good that it had been voluntary to take on the role of an actor, while others felt that it would have been better in terms of equality and learning if all students had been involved in both roles. “I thought it would have been more pleasant and definitely better for learning if all students had participated in both roles, as actors and observers. Despite of the fact that I volunteered to participate in acting, I felt my position was unequal to those who only observed.”
“…I noticed that, as I was an observer in the simulation of the first group, it was possible to learn different things through both methods.”
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Some of the students involved as actors perceived that it had been hard for them to divest themselves of the role they had played in a scenario even though the roles had been dissolved as a part of the debriefing. While the students understood that the roles were predetermined, some students were also worried that others had considered them to be like the characters they had played in the scenario. “…methods should be learned to help students let go of the roles assigned to them in the exercises or prevent them from getting too deeply caught up in the role.” Students' personal factors connected to learning were divided into two subcategories: students' own personal experiences and interaction in the group. There was a lot of reflection on personal factors, such as emotional experiences. In particular, acting in the roles had evoked emotions in the participants, but those who had operated as observers also described feelings provoked by the simulation exercises. For some of the students, the simulation exercises had aroused unpleasant memories from their childhood, youth or career. “(The simulation) event stirred up some bad personal memories from the past…” Interaction, reflection and discussion within the group were generally viewed to have been positive for personal learning. “…the interaction and communication of our entire student group was precisely what it should be in a group. Even though the simulation situation was new to some, no one was neglected; everyone was able to produce their own discussion or to express an opinion.” Some of the students found it empowering that the groups had included students from different stages of their studies and from different orientation studies; this inclusion had helped them to gain different perspectives in the discussions. Instruction given by teachers and questions used to guide discussion were also considered important.
Discussion This study introduced the issue of applying the simulation method in the interpersonal communication education of nursing teachers, managers and experts; this application included consideration of situations containing challenging interaction. A novel and significant finding was that the methods used in the simulation teaching of emergency care are not necessarily applicable as such in learning interpersonal communication competence. This was particularly emphasised in the debriefing. Some of the students participating in this study felt that the debriefing did not fully match the learning goals. This finding can be explained by the fact that the set of questions adopted from the simulation training of emergency care (what kinds of actions should be repeated and what should not) is not directly applicable to communication education. Therefore, in the future, it is important to construct questions that help students to observe and reflect on communication, e.g. managing interpersonal relationship and displaying appropriate, effective and functional behaviour in the given situation. Moreover, in order to succeed in creating questions that are aligned with the study aims, testing and applying different structured methods in the debriefing is essential. As shown in the literature (Sutherland et al., 2012), the fishbowl method, for example, can be a valuable and effective structure so that they correspond with the goals. Additionally, students must be allowed to solve challenges at their own pace when they feel up to the task. This study also highlighted the role of the teacher in supervising students' learning. Teachers need flexibility and they assume different roles during simulation exercises based on the target group, learning
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goals, and content of the course (Dieckmann et al., 2009). One of the central tasks is to recognise students' emotional experiences triggered by the simulation exercises. In this study, some of the students found parallels between acting in the roles and performing in general; therefore, they found the situation to have produced feelings of stressful and anxiety. Moreover, some had interpreted the debriefing as personal criticism, even though this was not the intention. These experiences seemed to be provoked by the questions and the teachers' guidance in the debriefing. Therefore, one of the key competences needed is teachers' ability to pay close attention to and interpret students' emotions stimulated by simulation exercises as part of their guidance. Thereby teachers can help students transform negative emotions into positive learning experience (Lahtinen, 2008; Zhang and Zhang, 2013; Goldman and Goodboy, 2014). Questions used to guide the debriefings and the actions of teachers are particularly significant in this process. In addition, students need to practice acting in the roles, going through the emotions emerging as a result of the simulation exercise and reflecting on the situations together. Previous studies have indicated that students' experiences of simulations are influenced by what kinds of roles they are given when realising a scenario (Paskins and Peile, 2010; Pearson and Mc Lafferty, 2011). In this study, students felt that they had learned from their positions as both actors and observers. Therefore, in the future, they should be encouraged to participate in simulation exercises in both roles. Moreover, it is important to remind the students that they are acting in predetermined and assigned roles, not as themselves. This study confirmed that interaction within the student group has an important effect on learning experiences (see e.g., Lefroy et al., 2011). This result can be explained by the fact that some of the students had previous experiences of simulation exercises, while the method was completely new to others. Furthermore, the majority of the students had acquired previous work experience, which allowed them to link and apply the issues dealt with in the simulation exercises in their future professions (see also Pike and O'Donnell, 2010; Rosenzweig et al., 2008). During the prebriefing, it is important that teachers guide their students towards the goals of the assignment and towards adhering to a mutual agreement (Dieckmann et al., 2009; Page-Cutrara, 2014). Collaboration between students and positive atmosphere should be fortified from the very beginning of the course by means of cooperative tasks (Lahtinen, 2008). As noted by Goldman and Goodboy (2014), the influence of personal characteristics, previous educational experiences, and emotional processes have a considerable impact on students' desire and ability to learn. The research provides valuable information for developing the simulation method in learning interpersonal communication competence in the field of health sciences; this knowledge can be exploited in other fields as well. All the authors of this article were involved in the data collection, and in the simulation exercises either as a participant or as a teacher, which strengthens the validity of this study. However, since the study population included students only of a single course, the results cannot be generalised. Further study is needed in order to get more information about students' learning experiences, especially in the debriefing. Conclusions Simulation is a valuable method in developing the interpersonal communication competence of master-level students of health sciences; the simulation itself has at its core activities based on interaction and cooperation. Communication education requires observation and questions which both guide debriefings to help students to reflect on their experiences, to understand interpersonal communication as a phenomenon, and to process emotional experiences. It is worthwhile to encourage students to participate in simulations as both actors and observers. The role of teacher is crucial in supervising students' learning and they need courage to develop new methods of simulation teaching.
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Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
The simulation method in learning interpersonal communication competence—Experiences of masters' degree students of health sciences Terhi Saaranen a,⁎, Anne Vaajoki a, Marjaana Kellomäki b, Marja-Leena Hyvärinen c a b c
University of Eastern Finland, Faculty of Health Sciences, Kuopio Campus, Department of Nursing Science, P.O.B 1627, 70211 Kuopio, Finland Kuopio University Hospital, Development, Clinical Education and Research Unit of Nursing, P.O.B 100, 70029 KYS, Finland University of Eastern Finland, Kuopio Campus, Language Centre, P.O.B 1627, 70211 Kuopio, Finland
a r t i c l e
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Article history: Accepted 16 December 2014 Keywords: Simulation Nursing science Interpersonal communication Competence Education
s u m m a r y Background: This article describes the experiences of master students of nursing science in learning interpersonal communication competence through the simulation method. The exercises reflected challenging interactive situations in the field of health care. Few studies have been published on using the simulation method in the communication education of teachers, managers, and experts in this field. Objectives: The aim of this study is to produce information which can be utilised in developing the simulation method to promote the interpersonal communication competence of master-level students of health sciences. Design: This study used the qualitative, descriptive research method. Settings: At the Department of Nursing Science, the University of Eastern Finland, students major in nursing science specialise in nursing leadership and management, preventive nursing science, or nurse teacher education. Participants: Students from all three specialties taking the Challenging Situations in Speech Communication course participated (n = 47). Methods: Essays on meaningful learning experiences collected using the critical incident technique, underwent content analysis. Results: Planning of teaching, carrying out different stages of the simulation exercise, participant roles, and students' personal factors were central to learning interpersonal communication competence. Conclusion: Simulation is a valuable method in developing the interpersonal communication competence of students of health sciences at the masters' level. The methods used in the simulation teaching of emergency care are not necessarily applicable as such to communication education. The role of teacher is essential to supervising students' learning in simulation exercises. In the future, it is important to construct questions that help students to reflect specifically on communication. © 2014 Elsevier Ltd. All rights reserved.
Introduction Expectations are high regarding the interpersonal communication competence of health care professionals. They are expected to be able to adapt themselves to constantly changing situations and interactive relationships, e.g., in different negotiation, group, and conflict situations (Myers et al., 2011). Such competence is a central component of the expertise of health care personnel (Ministry of Education, 2006; Finnish Patient Safety Strategy, 2009–2013, 2009; Health Care Act, 1326/2010, 2010). It has been indicated that, e.g., well-functioning interpersonal communication promotes collaboration within and between work groups (Brindley and Reynolds, 2011). Therefore, masters' level education in this field must prepare students for challenging interpersonal situations and ⁎ Corresponding author. Tel.: +358 500 940 242. E-mail addresses: terhi.saaranen@uef.fi (T. Saaranen), anne.vaajoki@uef.fi (A. Vaajoki), marjaana.kellomaki@kuh.fi (M. Kellomäki), marja-leena.hyvarinen@uef.fi (M.-L. Hyvärinen).
http://dx.doi.org/10.1016/j.nedt.2014.12.012 0260-6917/© 2014 Elsevier Ltd. All rights reserved.
provide them with interactive skills required by their future work positions. Interpersonal communication occurs in relationships between individuals as a result of cooperation between different parties (Spitzberg and Cupach, 2011). Competence in it is formed by cognitive, skill-related and affective aspects. The cognitive aspect contains the idea that the communicator knows and understands what effective interpersonal communication requires and what is expected from it. The skill-related aspect refers to displaying appropriate, effective and functional behaviour in any given situation and interpersonal communication relationship. The affective aspect includes the motivation, feelings and attitudes of participants. Interpersonal communication competence is constructed by the cooperation of the different participants in interaction and it is closely related to the topics of respecting others, tolerating differences and being ready for personal development (Spitzberg and Cupach, 2011). In the development of interpersonal communication competence, the simulation has been found to be an effective and useful method
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that fosters reflective learning (Brindley and Reynolds, 2011). Simulation imitates real-life situations and makes genuine phenomena and processes visible in fictional conditions (see Bambini et al., 2009). In the field of health care, simulation learning has proved to be an effective pedagogical method which develops not only clinical abilities but also interactive competence in different “real” health care settings (see e.g., Berragan, 2011). However, research on the topic has thus far concentrated either on examining the use of this method in clinical training (e.g., Bambini et al., 2009) or applying simulations in expert– client interactions (Koponen et al., 2012). Few studies have been published on the use of simulation in the context of interpersonal communication training of health care teachers, managers and experts, which is the focus of this study. Background Literature Research has indicated that simulation exercises improve students' interpersonal communication skills (Moule et al., 2008; Zavertnik et al., 2010; Pearson and Mc Lafferty, 2011), cooperative skills, and interaction occurring between different professional groups (Berg et al., 2010; Reese et al., 2010; Brindley and Reynolds, 2011; Pearson and Mc Lafferty, 2011; Reising et al., 2011; Wagner et al., 2011). There is also evidence that simulations enable increasing students' interest in the topic of interpersonal communication competence (Berg et al., 2010; Bosse et al., 2010; Koponen et al., 2012) and increase their professional confidence and trust in their own skills (Rosenzweig et al., 2008; Bambini et al., 2009; Kameg et al., 2010; Pike and O'Donnell, 2010). Students consider simulation to be an interesting, enjoyable and useful learning method (Kameg et al., 2010; Pearson and Mc Lafferty, 2011). As a learning process, the simulation method combines several different learning theories. It may include features of cognitive, social, realistic, constructive and experiential learning. According to cognitive learning theory, students utilise their previously acquired knowledge in a simulation learning situation and actively reflect on what happened in the situation, what was learned from it and what could have been done differently. From the perspective of social learning theory, simulation learning occurs in social interactive situations among students by observing others' working, their competence and behaviour (Rutherford-Hemming, 2012). According to realistic learning theory, students' perceptions related to their knowledge, skills and attitudes based on reality are highlighted in simulation learning. Moreover, constructive learning theory emphasises that learning occurs through active, experiential and social collaboration (RutherfordHemming, 2012). Simulation learning is also strongly connected to Kolb's (1984) experiential learning theory. The experiential learning cycle can be divided into four separate stages in which all steps are closely interconnected, forming a learning cycle. Learning is founded on a learners' subjective and personal experience related to an encountered topic or experience and connected activities. The learner simultaneously reviews and reflects on different aspects of the subject and thus builds new understanding of applications or changes in operations. During the subsequent conceptualisation stage, the learners' aim at modifying their previously acquired knowledge and creating new operational models and theories, after which the newly learned subject can be applied as a practical solution. (Dieckmann et al., 2009). In order to facilitate a successful and effective learning process, the teachers' ability to give instructions, guide the simulation and give feedback is significant (Wotton et al., 2010; Shinnick et al., 2011; Kable et al., 2013). Accordingly, debriefings, in which students have the opportunity to process the topics learned, combine topics with previously acquired knowledge and consider how this could be utilised in the future, form a particularly crucial stage. In sum, a simulation is an event in which interactive learning occurs through doing, experiencing, feeling and reflecting (Bambini et al., 2009; Dreifuerst, 2012).
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Aim In this study, the simulation method was applied in the communication training of teachers, managers, and experts in the field of health care. The aim was to examine what factors are important in students' learning of interpersonal communication competence using the simulation method. Methods Setting The Challenging Situations in Speech Communication course (1 credit point) was held in 2012, including simulation exercises that lasted two days. The simulation exercises were chosen to support the learning objectives of the course, viz., to strengthen students' understanding of the importance of interpersonal communication competence and the core skills needed in health care professions. Before the simulation exercises, there were lectures on communication, and simulation as a learning method. The simulation method was adapted from emergency care simulation training which is well known and widely used in health care. All students had two scenarios in simulation exercises founded on real-life events: a challenging negotiation at a hospital ward (scenario 1) and evaluation discussion between a student, teacher, and staff, towards the end of the practical training period (scenario 2). The simulation exercises were conducted in a simulation room, guided by both the speech communication and nursing science teachers working as pairs. The simulation exercises were performed in three different groups. Each group had approximately 20 students. From these students four to six were actors in each scenario, and the rest (n = 15) were observers. The simulation exercises involved three phases: the prebriefing, the simulated practice scenario, and the debriefing (Rhodes and Curran, 2005; see also Page-Cutrara, 2014). At first, teachers carried out a prebriefing, i.e., an orientation for the entire group. Next, volunteer students were asked to act in predetermined roles in the scenario, not as themselves. One of the teachers instructed the actors before the beginning of the scenario. Simultaneously, another teacher gave instructions to the rest of the students on making observations of the scenario. They were asked to observe what kinds of actions should be repeated and what should not. In summary, the simulation exercise included a prebriefing (60 min) and the scenario itself (15 min), during which teachers instructed the students functioning in the roles via a microphone. After the scenario, the entire student group gathered to participate in a shared debriefing guided by the teachers (45–60 min). The scenario was documented on video and the recording was utilised in the debriefing. Data Collection This study used the qualitative research method. The data were collected using the critical incident technique in the form of essays, which made it possible to acquire multifaceted and profound information on the phenomenon studied (Schluter et al., 2008; Vachon and LeBlanc, 2011). In these essays, students were instructed to describe one positive and one negative learning experience from the simulation exercises. Subsequently, students were asked to select one of the experiences for further analysis; to scrutinise how the positive or negative learning experience that they had chosen had attained significance. Furthermore, the students were instructed to reflect their experience on their reading of literature and to consider how they could exploit what they had learned in their future work as preventive nursing experts, nursing managers or health science teachers. The students were encouraged to write about their learning experiences immediately or within two weeks after the latest simulation exercise.
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Altogether 58 students in three different groups took part in the course. From these students, 50 students consented to the use of learning assignments in the study, and three essays were rejected, because they did not deal with the students' experiences of the simulation exercises. Altogether 47 essays were included in the final analysis (response rate 81%). There were 154 pages of written material consisting of students' essays.
on the critical incident method was a mandatory part of the course, but submitting an essay for the study was voluntary. The students were informed both orally and in writing that the learning assignment was to be handled with confidentiality and anonymously throughout the entire study and that all personal data would be removed and could not be divulged during any stage of research. Students were also informed that the essays were not to be published as such anywhere. Subsequently, students submitted their written consent to participate in the research.
Data Analysis The essays underwent inductive content analysis (Elo and Kyngäs, 2007; Polit and Beck, 2012). First, to get a general view, the data were read carefully several times. Second, in order to make sense of the data as a whole, the units of analysis were selected. An individual sentence or several words or sentences which together had unified a concept made up one unit. At this stage, the data were classified and subcategories were formed. Each subcategory was labelled using words denoting content-characteristics. Thereafter, all the subcategories were combined into four high-level categories, which were also based on the content. Finally, the main category was identified and named factors connected to learning interpersonal communication competence through the simulation method (see Fig. 1). While the analysis itself was conducted by one researcher, the different stages of analysis were processed and developed in cooperation with the research group in different stages. Ethical Considerations The entire research was performed according to the ethical principles presented in the guidelines of Responsible conduct of research and procedures for handling allegations of misconduct in Finland (Guidelines of the Finnish Advisory Board on Research Integrity, 2012). Writing an essay
Results Based on the data, the main category of factors connected to learning interpersonal communication competence through the simulation method included four high-level categories: planning of teaching, carrying out the different stages of the simulation exercise, participant roles, and students' personal factors. As shown in Fig. 1, every high-level category was formed by combining different subcategories. According to the students' essays, planning of teaching helped to build a foundation for learning. The connection between aims and their realisation, the planning of scenarios, the size and timetable of the group, and considering study orientation emerged as central themes in the essays. When considering the connection between aims and their realisation, students expected the activities to be constantly consistent with the aims of the course. Some of the students felt that the aims had been reached, while others found that the simulation exercises had not entirely corresponded with the goals set for them. This view emerged particularly in connection with the debriefings, in which there was some digression from the course aims. Students found the scenarios, dealt with already familiar topics, to be appropriate, realistic, and educational. They were also able to connect
Fig. 1. Factors connected to learning interpersonal communication competence through the simulation method.
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the topics to their experiences from working life or to consider the usefulness of what they had learned in their future work positions. “For me, a positive experience emerging from the first simulation event was that in its similarity, the entire presentation situation strongly reminded me of my workplace's…meetings” “…you learned a lot about the simulation situations and the learning method in question fit the classes and was rewarding” Some of the students found the timetable of the simulation day overtly strict or the group sizes too big. “The simulation day should be longer or the groups smaller so that everyone could participate.” Considering students' different orientation studies (nursing management and leadership, preventive nursing science and nurse teacher education) was also deemed important. Students highlighted the view that the scenarios should be relevant regardless of the study orientation. The students felt that they had learned from all of the different stages of the simulation exercise: the prebriefing, the simulated practice scenario and the debriefing. A clear introduction to the topic was provided during the prebriefing as the simulation was a new experience for some of the students. The students were pleased with the fact that they were told about the simulation methods and informed about what they could learn from the simulation exercises before the simulation occurred. “As the day began, we were told that the situations that we were going to portray were connected to concrete circumstances that anyone of us could come across in the working life. This felt good and inspired us…” When carrying out a simulated practice scenario, students valued the atmosphere, the length of the exercise and getting guidance from teachers in the situation. A number of students felt that the amount of guidance they had received was satisfactory. They found that it was better that they got to think for themselves, e.g., on how to proceed with their roles as actors in a scenario. Conversely, others found the amount of guidance inadequate, which caused a sense of insecurity in them. The responses on the topic of the debriefing highlighted the importance of reflection, the challenges related to taking the roles apart, and watching the video recordings of the scenarios. The students found that the discussions had dealt with the contents of interpersonal communication competence in a versatile way. Students experienced the discussions as fruitful and constructive, and the time reserved for it was perceived as sufficient. Moreover, guidance received from teachers was considered important although some felt that they needed more of it. Some of the students considered that watching the video recordings had been educational, while others considered this futile or even saw it as a source of anxiety. The participant roles in the simulation exercises were comprised of actors and observers. The students described that they had been able to learn from both roles. Some considered it good that it had been voluntary to take on the role of an actor, while others felt that it would have been better in terms of equality and learning if all students had been involved in both roles. “I thought it would have been more pleasant and definitely better for learning if all students had participated in both roles, as actors and observers. Despite of the fact that I volunteered to participate in acting, I felt my position was unequal to those who only observed.”
“…I noticed that, as I was an observer in the simulation of the first group, it was possible to learn different things through both methods.”
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Some of the students involved as actors perceived that it had been hard for them to divest themselves of the role they had played in a scenario even though the roles had been dissolved as a part of the debriefing. While the students understood that the roles were predetermined, some students were also worried that others had considered them to be like the characters they had played in the scenario. “…methods should be learned to help students let go of the roles assigned to them in the exercises or prevent them from getting too deeply caught up in the role.” Students' personal factors connected to learning were divided into two subcategories: students' own personal experiences and interaction in the group. There was a lot of reflection on personal factors, such as emotional experiences. In particular, acting in the roles had evoked emotions in the participants, but those who had operated as observers also described feelings provoked by the simulation exercises. For some of the students, the simulation exercises had aroused unpleasant memories from their childhood, youth or career. “(The simulation) event stirred up some bad personal memories from the past…” Interaction, reflection and discussion within the group were generally viewed to have been positive for personal learning. “…the interaction and communication of our entire student group was precisely what it should be in a group. Even though the simulation situation was new to some, no one was neglected; everyone was able to produce their own discussion or to express an opinion.” Some of the students found it empowering that the groups had included students from different stages of their studies and from different orientation studies; this inclusion had helped them to gain different perspectives in the discussions. Instruction given by teachers and questions used to guide discussion were also considered important.
Discussion This study introduced the issue of applying the simulation method in the interpersonal communication education of nursing teachers, managers and experts; this application included consideration of situations containing challenging interaction. A novel and significant finding was that the methods used in the simulation teaching of emergency care are not necessarily applicable as such in learning interpersonal communication competence. This was particularly emphasised in the debriefing. Some of the students participating in this study felt that the debriefing did not fully match the learning goals. This finding can be explained by the fact that the set of questions adopted from the simulation training of emergency care (what kinds of actions should be repeated and what should not) is not directly applicable to communication education. Therefore, in the future, it is important to construct questions that help students to observe and reflect on communication, e.g. managing interpersonal relationship and displaying appropriate, effective and functional behaviour in the given situation. Moreover, in order to succeed in creating questions that are aligned with the study aims, testing and applying different structured methods in the debriefing is essential. As shown in the literature (Sutherland et al., 2012), the fishbowl method, for example, can be a valuable and effective structure so that they correspond with the goals. Additionally, students must be allowed to solve challenges at their own pace when they feel up to the task. This study also highlighted the role of the teacher in supervising students' learning. Teachers need flexibility and they assume different roles during simulation exercises based on the target group, learning
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goals, and content of the course (Dieckmann et al., 2009). One of the central tasks is to recognise students' emotional experiences triggered by the simulation exercises. In this study, some of the students found parallels between acting in the roles and performing in general; therefore, they found the situation to have produced feelings of stressful and anxiety. Moreover, some had interpreted the debriefing as personal criticism, even though this was not the intention. These experiences seemed to be provoked by the questions and the teachers' guidance in the debriefing. Therefore, one of the key competences needed is teachers' ability to pay close attention to and interpret students' emotions stimulated by simulation exercises as part of their guidance. Thereby teachers can help students transform negative emotions into positive learning experience (Lahtinen, 2008; Zhang and Zhang, 2013; Goldman and Goodboy, 2014). Questions used to guide the debriefings and the actions of teachers are particularly significant in this process. In addition, students need to practice acting in the roles, going through the emotions emerging as a result of the simulation exercise and reflecting on the situations together. Previous studies have indicated that students' experiences of simulations are influenced by what kinds of roles they are given when realising a scenario (Paskins and Peile, 2010; Pearson and Mc Lafferty, 2011). In this study, students felt that they had learned from their positions as both actors and observers. Therefore, in the future, they should be encouraged to participate in simulation exercises in both roles. Moreover, it is important to remind the students that they are acting in predetermined and assigned roles, not as themselves. This study confirmed that interaction within the student group has an important effect on learning experiences (see e.g., Lefroy et al., 2011). This result can be explained by the fact that some of the students had previous experiences of simulation exercises, while the method was completely new to others. Furthermore, the majority of the students had acquired previous work experience, which allowed them to link and apply the issues dealt with in the simulation exercises in their future professions (see also Pike and O'Donnell, 2010; Rosenzweig et al., 2008). During the prebriefing, it is important that teachers guide their students towards the goals of the assignment and towards adhering to a mutual agreement (Dieckmann et al., 2009; Page-Cutrara, 2014). Collaboration between students and positive atmosphere should be fortified from the very beginning of the course by means of cooperative tasks (Lahtinen, 2008). As noted by Goldman and Goodboy (2014), the influence of personal characteristics, previous educational experiences, and emotional processes have a considerable impact on students' desire and ability to learn. The research provides valuable information for developing the simulation method in learning interpersonal communication competence in the field of health sciences; this knowledge can be exploited in other fields as well. All the authors of this article were involved in the data collection, and in the simulation exercises either as a participant or as a teacher, which strengthens the validity of this study. However, since the study population included students only of a single course, the results cannot be generalised. Further study is needed in order to get more information about students' learning experiences, especially in the debriefing. Conclusions Simulation is a valuable method in developing the interpersonal communication competence of master-level students of health sciences; the simulation itself has at its core activities based on interaction and cooperation. Communication education requires observation and questions which both guide debriefings to help students to reflect on their experiences, to understand interpersonal communication as a phenomenon, and to process emotional experiences. It is worthwhile to encourage students to participate in simulations as both actors and observers. The role of teacher is crucial in supervising students' learning and they need courage to develop new methods of simulation teaching.
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