Simulation activity also requires simulation competency. In several studies, simulation activity is reported to be a learning situation with "A rollercoaster of emotions" [9]. To achieve learning, it is of importance that the learner can handle the feelings that appear in the setting [10]. Being an actor in the scenario means being exposed and can easily lead to feeling overloaded and vulnerable [11, 12]. It can easily end up with the actor being pushed far out from their comfort zone and into what can be called the discomfort zone [13]. In this zone, no learning is achieved when overloaded by feelings and stress. Defensiveness and self-protection might occur, meaning poor learning conditions with feedback not being timely given to support learning [8, 10, 14]. Against this background, we have tried in this project to facilitate a learning climate that promotes experimental learning, guided by participants' needs, and downplays individual performance. We want to highlight some aspects and tools that have been used in this online simulation activity setting that are equally relevant and can be transferred to simulation activity in general.

To summarize, both groups were satisfed with the online simulation activity. They all valued having time and space and the opportunity to meet and refect together in a setting like this. There was a common perception of the importance of carrying out RN-NA simulation training regularly. Online simulation activity might increase the possibility for more frequent meetings. The students stated that the

online simulation worked "surprisingly well" and claimed that an online simulation activity for an interdisciplinary group such as theirs can be an effective and resourcesaving way of learning. However, they pointed out that it depends on detailed and specifc planning and organization. The information provided to the participants beforehand must be clear and concrete so they know the schedule, everybody's role and what is expected from each and everyone. A timeline and organization of breakout rooms must be published. The students expressed a need for a designated leader who knows the intention of the refection and discussion part of the debrief before going to the breakout rooms. It saves time and increases the effciency of group work. If possible, they would prefer that a teacher could visit the breakout room and facilitate the conversation. These statements have support in the literature and research; in building a community for learning, the students need to know/develop/ build understanding, rules and agreement on how to communicate, the value of discussion and diverse viewpoints [11, 15].

The students emphasized the importance of being involved in developing the scenarios and that it was fellow students who performed in the scenarios. It made the focused themes directly relevant to their clinical practice, and it increased their involvement and engagement—highlighted in the literature as important factors for simulation competency [15]. The students reported having achieved an increased awareness about similar situations which often occur in their clinical daily life. Later one student exemplifed her increased awareness by describing a meeting with a young RN with little clinical experience. She (the NA) was more active in supporting the RN. She described how important this cooperation was for both.

However, several of the NA students in particular pointed to the lack of face-toface connection when online simulation activity is implemented. On the other hand, several students described online meeting as a "mental space" leading to a situation that made it easier to take the foor and participate in the discussions than when they all are present in the same room. Group dynamics and hierarchy between professions seem to be an obstacle for some students. This may prevent them from taking the foor and speaking out. As one NA student expressed: "There would be too much tension in the room". Online simulation activity seemed to facilitate the reduction of this tension. One of the students expressed this as follows:

Maybe it is easier to share the space – to bring more balance in the discussion online because we are more aware of bringing everybody's voice into the group. In a situation with physical presence, the challenge is often that the groups are unbalanced when it comes to who is verbally active or not.

In the online simulation activity setting, the video flming of the scenarios was carried out just by those involved and without an audience. A short debriefng was implemented focusing on how the students perceived the scenario and the setting, including a debriefng related to the performer's feelings. About a week passed between the recording of the flm and the online presentation. One of the performers said that this break between implementing the scenario and the online simulation activity day was valuable for his learning. He said:

I was one of the persons who took part in the taped scenario. Online simulation made it easier for me to achieve the necessary distance for being a part of the debriefng/refection. In a live simulation situation, this would be more diffcult.

The "break" between being an active actor in the scenario, which is a stressful exercise, and then after some days viewing oneself on screen is probably expedient. The performers had time to gather their thoughts and take control, which enabled them to learn and receive feedback [10, 14].

When a student was designated as an actor in the scenario, they acted on behalf of a group that had discussed and decided how this role should be played. This reduces the focus on individual performance, choice and behaviour and contributes to a learning community with more open discussions and less need for defensiveness and considerations about personal vulnerability.

Student involvement in the development of cases and scenarios made simulation activity learner centred. The facilitation of exploration of what they consider relevant issues in new scenarios was experimental and practice oriented. Being responsible for determining focus and exploring solutions reduced stress.

We had many scenario options that were developed together with the students, which led us to believe that they were relevant learning resources. This way of carrying out the simulation's activity can give the facilitator a feeling of lack of control, uncertainty about what is happening and challenges in maintaining focus and keeping to the time framework. However, we believe that facilitating such an experimental process of learning results in a greater degree of learning in this context than when everything is predetermined and teacher directed.

#### **5 Conclusion**

This pilot project involved transferring simulation activity from physical meetings of the participants in a simulation centre to simulation activity as online learning. The possibilities physical meetings (face to face) provide for spontaneity, nonverbal communication and eye contact are diffcult to replace in an online setting. However, based on the students' and teachers' evaluations, it seems that such a learning approach can be an effective and rational way of learning. Nevertheless, this requires thorough preparation, well-thought-out organization and detailed information for everyone involved. When the students are videotaped in the scenarios, further use requires the student's consent and an awareness of the necessity to protect students' privacy. The dependence on the technology makes the setting vulnerable and requires for everybody involved habituation and cooping.

These preconditions are well known from recommendations about simulation activity in general and do not differ signifcantly when simulation activity is used in physical meetings. However, the online setting increases their signifcance when students cannot see each other's faces and/or who is joining "the room".

Based on our experiences, online simulation activity can be used as an effective and rational way of learning in addition to simulation activity in the form of physical meetings.

#### **References**

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

## **The Use of Critical Response Process as a Debriefing Structure in Simulation Activity in Nursing Education**

Jon Viktor Haugom and Randi Tosterud

#### **1 Introduction**

To be a facilitator in simulation requires specifc skills and knowledge in simulation pedagogy [1]. Being a facilitator when using high-fdelity simulation as a learning approach might appear to be a challenging, complex, and exhausting role. A great deal of preparations must be made concerning the practical prepping of mannequins, available equipment, surroundings, technology, adequate advance information to the participants, and cooperation with the staff involved. Moreover, insight into the target group's starting point for learning is required, as well as awareness of the timeframe and learning outcomes. This also includes welcoming the group in a way that facilitates a safe and good learning climate and briefng the participants about equipment and technology. During the scenario, facilitating learning for both the group of actors and the group of responders must be kept in mind. In the debriefing, the facilitator must help the actors control and handle their feelings. Furthermore, the facilitator must act as a group leader, and is not only expected to be an expert in the current feld but also to be learner-centered focused. All the participants must be engaged in active refection and feedback. The learning outcome must be focused, but the facilitator also needs to improvise and prioritize depending on what appears as interesting and challenging for the participants to discuss. Realistic feedback must be given in a way that encourages the learners to listen, understand, and improve and progress in their learning. The facilitator is dependent on the current group size and dynamics—inspiring and stimulating when the dynamic appears as active, supportive, dialogical, and engaged, but exhausting and depressing when it is silent, monological, closed, and passive. Clearly, the facilitator needs tools to handle the simulation activity.

J. V. Haugom (\*) · R. Tosterud

Department of Health Sciences Gjøvik, Norwegian University of Science and Technology, Trondheim, Norway

e-mail<EMAIL_ADDRESS><EMAIL_ADDRESS>
I. Akselbo, I. Aune (eds.), *How Can we Use Simulation to Improve Competencies in Nursing?*, https://doi.org/10.1007/978-3-031-10399-5\_6

In this chapter, we want to present a structure for feedback which can help the facilitator to achieve their main objective of enabling the participants to achieve learning. But frst a short summary of what is known about simulation, debriefng, and feedback is presented.

#### **1.1 Simulation Activity as a Learning Approach**

Simulation activity is a resource-intensive learning approach due to the equipment required, the learning surroundings, and people involved in operating and facilitating. It offers the potential for learning beyond the learning outcome such as training in feedback literacy and professional argumentation, situational awareness, and teamwork training. These are all considered to be important factors in building a patient safety culture. A patient safety culture requires everyone to have the courage to raise their voice and involves an openness to failures and success, mutual support, receiving and giving feedback, and a shared responsibility. The students need training during their education to participate in such learning environments with the aim of developing such knowledge, skills, and attitudes.

Learner-centered and lifelong learning are emphasized in higher education and require the learner to be active in learning and not to be dependent on teachers or facilitators. It requires learners to be able to evaluate their own performance, to identify their lack of skills or knowledge, and to take responsibility for progress in their learning. The strength of simulation activity is that it facilitates experimenting, failure, and detection of defciencies, all learning conditions which are not possible in the clinic. However, if these additional effects are to be exploited, this must be refected in how the simulation is carried out and how the debriefng is structured. Simulation activity offers the potential to supply what is underscored in higher education today: active learning, interprofessional learning, collaborative learning, and learner-centered learning [2–5]. Simulation is widely applied and frequently used in healthcare education and is often also used to maintain or enhance competency in healthcare units. Simulation can be used to help transfer theory into practice, improve logistical fow, and facilitate training in technical and non-technical skills [6]. In a simulation scenario, the participants can experience challenges in both handling a situation, communication, relational conditions, and personal factors. Thoughts emerge from what we see, hear, or touch and must be further developed into learning through refective thinking [7]. This is known in the simulation activity as the debriefng phase.

The debriefng is considered crucial to achieve learning. The purpose of the debriefng is that the participants reexamine what took place in the scenario. This is a refective learning process to help promote the development of clinical reasoning and judgment skills in an active learning environment. Debriefng offers the possibility to give and receive feedback, to resolve feelings, as well as the opportunity to learn from either successes or failures [1].

Let us take a closer look at the important factors for achieving learning from feedback.

#### **1.2 Feedback as Part of Debriefing**

Feedback is considered important in learning in general and an important part of the debriefng. Teachers and fellow students are important givers of feedback, as are colleagues and managers in working life. However, even if we all understand and appreciate feedback, it is regarded as a complex and multilayered concept with no common and agreed understanding of how to offer and provide it to achieve learning [8]. Lefroy et al. [9] offer a defnition of feedback supporting self-regulating learning as follows:

*Helpful feedback is a supportive conversation that clarifes the trainee's awareness of their developing competencies, enhances their self-effcacy for making progress, challenges them to set objectives for improvement, and facilitates their development of strategies to enable that improvement to occur.*

For feedback to contribute to learning, the students need to handle their emotional and relational reactions, and they need to have the chance to express themselves. They must appreciate the feedback and understand how it can be used in further learning and individual growth. This shows that the prerequisite for feedback to have a learning effect is that it is carried out as a dialogue [8].

Transferring this knowledge into a simulation setting is highly relevant. Even though it is emphasized that simulation is for learning, students report simulation to be stressful in terms of being put in the spotlight and assessed, while in their performance they are exposed in relation to both body and mind [10]. In particular, those performing in the scenario report that they feel in a vulnerable position that is characterized by a high risk of disgracing themselves and ending up in a stressful and intrusive situation [11, 12]. The feeling of having to defend and protect themselves might arise, which reduces their ability to make use of the feedback they receive [9, 13].

Studies reveal disappointing results showing that debriefng seems to be more based on the facilitators' frames and dominance than the participants' frames [5]. The facilitator tends to assume a role of prominence as in teaching in general [14], which does not accord with recommendations for stimulating students as self-regulated learners [9]. The facilitator's feedback style and communicative abilities in facilitating are crucial and have a great impact on the learning climate [15, 16]. It is emphasized that the facilitators would beneft from practicing techniques for stimulating involvement and refective practice in the participants [5, 15].

There is no clear evidence of when or how debriefng should be implemented to achieve learning and change [17, 18], but it seems that structuring the debriefng is of importance. Several frameworks are available to help structure debriefng in a purposeful manner [1]. However, the development of appropriate frameworks and ways of structuring debriefng adapted to the participants' needs and the learning outcomes represents an ongoing process. There is also a need for further in-depth research into how dialogic feedback can enhance student learning [8].

#### **1.3 Critical Response Process as a Structure for Debriefing**

In the following, we present a structure for feedback called critical response process (CRP), evolved by Liz Lerman [13]. CRP underscores the value of dialogue, inquiry, and peer feedback, and it offers the actors the opportunity to exercise a degree of control in the criticism directed at their work based on the perception that "When defensiveness starts, learning stops" [13]. CRP originally evolved as an approach to group critiques on artistic work in progress. However, Lerman claims that its fexibility makes it suitable for different types of learning situations that involve feedback. The roles involved are artist(s) (called the actors in medical simulation), respondent(s) (one, few, or many), and a facilitator. These are parallel roles used in medical simulation, though respondents are often called observers. Inspired by Lerman's work, we used this structure in debriefng as part of simulation activity, and in the following, we describe how we transferred and used CRP in medical simulation.

CRP includes a four-step method [13] summarized in Table 1.

#### **1.3.1 Phase 1 Statements of Meaning**

The respondents are requested to prepare one or two positive statements and formulate open questions about the actors' performance. When the debriefng starts, each respondent gives the actors one response at a time on something they found to be good practice, impressive, engaging, thought-provoking, and interesting. Only positive feedback should be given at this stage with no addition of "… but…." Several rounds may be necessary to obtain all the positive responses. The rationale for this is that everyone must make their voice heard and give positive feedback at this frst stage, which will probably lower the threshold for taking the foor in the later stages. The respondents address their feedback directly to the actors. Thus, the responsibility for providing feedback is established as a common concern and contributes to a standard of shared responsibility. The respondents describe what they found engaging and what was impressive and good practice, resulting in less focus on the facilitator's feedback. Such reinforcement of what was done well promotes a climate of trust and learning. Consequently, this phase confrms good practice and what can be learned from it. Being the one to perform the scenario can be a stressful experience, and when entering the debriefng, studies have shown that the actors feel cognitive and emotional overloaded and vulnerable [11, 12]. At this stage of the feedback, the actors get a well-deserved break after the stress of performing the scenario, and they are flled in with positive descriptions of their work. This gives them time to gather

**Table 1** Critical response process

their thoughts and take control, enabling them to receive further feedback with reduced emotional distress and self-criticism. These are all factors which are underscored in providing useful feedback and thereby achieving learning [9, 13].

#### **1.3.2 Phase 2 Actors as Questioner**

In this phase, the actors raise all their questions about their own performance, and the respondents answer honestly, discuss, and refect. This makes the feedback learner-centered in that it is controlled and based on the actors' need for learning and understanding of the situation. The respondents propose answers leading to refection and dialogical feedback.

The actors keep control by raising questions about their own performance. This phase reduces the need for the respondents and facilitator to give negative feedback on mistakes, wrong priorities, or a lack of skills and knowledge. It is easy to give honest responses because the actors ask for it. The positive climate in this phase seems to enable the actors to dare to put their practice under debate, being open for responses which lead to further dialogues between the students about alternative solutions and priorities implemented in the scenario. By themselves being the ones who put their actions and priorities under debate, they keep control and are open to feedback on what they themselves perceive as relevant issues from the scenario. This provides the facilitator and the respondents with insight into the actors' needs for refection and learning.

#### **1.3.3 Phase 3 Neutral Questions**

Each respondent asks the actors neutral, open-ended questions about their performance. Being an actor in the scenario means to be exposed. Defensiveness and self-protection may occur, leading to poor learning conditions and feedback not being given in timely manner to support learning [9, 13]. Neutral and open questioning gives the actors the opportunity to discover, explain, refect on, and assess their own practice. Emphasizing open and neutral questions does not trigger the need for defense but facilitates for feedback as a supportive conversation. If necessary, the facilitator must help the respondents reformulate questions so that they are open and neutral, leading to a question-based dialogue. This phase can help increase participants' awareness and training in giving and receiving feedback in general and is an important additional effect of simulation activity. It is important that the facilitator creates a climate that involves an openness to failure and success, where all participants are aware of the importance of mutual support for good cooperation. Simulation activities can offer a learning environment aimed at enabling students to develop abilities which are considered important in building a patient safety culture.

To avoid taking focus away from valuable discussions and conversations between the actors and the respondents, it is an advantage if the facilitator waits until the students have given feedback and asked their questions. However, the facilitator must ensure the quality of comments from the respondents and the actors to ensure professional soundness.

#### **1.3.4 Phase 4 Option Time**

Each respondent offers the actors suggestions or advice for change, opinions, and strategies for further learning. The advice/suggestions must be honest, concrete, and understandable for the recipient. The advice and suggestions deal with progress in learning and strategies for further learning. This is done in a kind of ritual by the respondent telling the actors what the advice/suggestion is about and then asking if they want to receive it. An example could be "I have some thoughts about how you communicated with the patient. Would you like to hear these?" The actor(s) has the option to answer yes or no. This ritual seems to be perceived as rather weird by the students; often smiles and humor appear in this phase. The ritual of telling the content of the advice and asking if they want to receive it is based on the goal of giving explicit control to the recipient of feedback. There is no point in giving feedback if the recipient is not motivated or responsive.

The option/advice is often positively charged ("Keep on like you showed us today; it was impressive") but also includes areas for improvement and how to proceed in learning. The facilitator possesses many roles in CRP: to relieve the performers if they are highly emotionally affected and to prevent the focus on the negative aspects that accompany free discussion. However, sometimes, the facilitator should act as "the bad guy" if the respondents are too polite or reluctant to give honest advice about lack of skills, knowledge, and attitudes for good practice. In a patient safety perspective, simulation activity might be a dangerous way of learning if the actors leave the setting with a false self-esteem and belief that this went well without recognizing the need for more training and learning to improving practice.

#### **1.4 Exploring Two Structures for Debriefing and How They Influence the Facilitator Role**

There is a lack of knowledge about how to structure debriefng to achieve the purpose of the simulation activity, which is active and learner-centered learning, and less dominated by the facilitator's frames and control. Inspired by this, we decided to conduct a study using a quasi-experimental multi-method, comparative design. A full presentation of the study has been published [19].

Two structures for debriefng were included. The frst was a well-known structure in medical simulation, the Steinwachs structure [20], originally developed to facilitate the debriefng phase in gaming education. It includes the recommended minimum phases of reaction, analysis, and summary [1]. In the frst phase, the description phase, the facilitator challenges the actors to describe what occurred in the scenario, with the intention of airing their experiences and impressions and exchanging their perceptions with the respondents. In the second phase, called the analogy/analysis phase, the actors explore, analyze, and refect on alternative solutions, relevance, success, and failure. In the third phase, called the application phase, the actors and respondents express what is particularly relevant and the consequences for further learning. The facilitator gives their attention to the learning/ refection process and strives to get everyone to participate in the debriefng and

contribute support in the discussion. This basic structure can be recognized in several of the available structures used in debriefng in medical simulation.

The second structure included was the critical response process (CRP). The rationale for the choice of including this structure was that it deviates from the recommended minimum phases of reaction, analysis, and summary [1]. To the best of our knowledge, CRP has not been previously used as a structure for debriefng in medical simulation.

The data was collected from the end of April to the end of May 2017, and all debriefng sessions were videotaped by using a Swivl iPad. Following the debriefing, the students completed the Norwegian translated version of the Debriefng Experience Scale [21], and the facilitator wrote notes after each debriefng.

The sample consisted of undergraduates in bachelor of science in nursing in the second year of their 3-year program. They were conducting their 9-week clinical practice, either in medical or surgical wards. Out of 168 students, 155 participated in the study. They were divided into 15 groups, with a group size between 6 and 13 students. To be well prepared, the students received the scenarios some days before the simulation activity. Two students performed each scenario, and the others were respondents. Immediately before starting the simulation activity, the facilitator randomly picked a note describing which structure (Steinwachs or CRP) to use in the current debriefng. The same facilitator facilitated all the simulation activity sessions.

Based on the results from the time registration of the facilitator's verbally prominent role and the students' response to the Debriefng Experience Scale, there was no difference between using Steinwachs and CRP structure. However, in analyzing the videos and facilitators' notes, the facilitator's role concerning control, dominance, and responsibility clearly differed, which in turn affected the actors' and the respondents' roles. Even though there was nearly no difference in how much of the time the facilitator talked, there was a clear difference in what they spent their time on.

When using Steinwachs structure, the facilitator appeared to have the dominant role. He was in control, being responsible for feedback, raising questions, verifying, and asking follow-up questions—a conversation that mainly included the actors in the scenario and the facilitator. The actors addressed questions and responses to him, and the whole group focused on the facilitator as illustrated in Fig. 1.

When using CRP, the facilitator's role seemed to be as a leader of the group discussion, introducing new phases and helping reformulate questions if necessary. Each phase of the CRP structure forced a transmission of the responsibility and control from the facilitator to the respondents and the actors, as illustrated in Fig. 2.

After using CRP, the facilitator noted their concern about losing control, a fear of not achieving the learning outcomes. Since the students were the ones giving feedback and asking questions, CRP seemed to safeguard a more comprehensive focus on the "nursing performance." In contrast, in the Steinwachs structure, the facilitator's feedback and questions seemed to break up the performance into details connected to the learning outcomes (ABCDE, communication, leadership). However,

when analyzing the videos and the students' responses to the questionnaire, learning outcomes appeared to be the dominant focus in both structures.

The two structures differ from each other from the start. The frst phase in Steinwachs structure involves the actors as actively being challenged to describe what they observed and which actions they took. However, the facilitator did not report to miss the description phase when using CRP. Often in the description phase, it was necessary to interrupt because the actors started to analyze immediately, sometimes leading to frustration and confusion because the actors could not see the difference between describing and analyzing.

In the beginning of the study, Steinwachs structure gave the facilitator the best feeling of control over the debriefng to ensure focus on the learning outcomes. As the study progressed, CRP became the preferred structure for the facilitator. Although the fear of losing control was still present, the facilitator felt it was a relief to transfer and share the responsibility for the debriefng with the respondents, and not have to make a big effort to stimulate student activity. Perhaps the facilitator's eagerness to keep control can hamper the students' learning. CRP gives the facilitator a better opportunity to focus on group dynamics, formulation of questions, and learning outcomes.

#### **2 Conclusion**

In this chapter, we have presented critical response process as a structure for debriefing based on a study focusing on how two different structures affected the facilitator role. In our experience, CRP offers a structure for debriefng that well facilitates active, learner-centered, and collaborative learning. It emphasizes feedback as maintenance of dialogue, mutual support, and open and non-judgmental responses, all of which safeguard essential factors for feedback leading to learning. CRP offers a great opportunity to put the ability to give and receive feedback on the agenda. This is an important part of learning and essential in building a patient safety culture. The responsibility for conducting a debriefng is transferred to the learners as intended, and the facilitator gets the chance to truly be a facilitator. An alternative when using CRP with many respondents is to divide them into groups so they can discuss and give their positive comments, questions, and action options as a group to the actors in the debriefng. This pre-debriefng will lead to a lot of extra learning, with discussions on how to formulate questions to achieve constructive conversations.

Debriefng is an important part of simulation activity to achieve learning. Feedback is a part of debriefng and is described as a complex and multilayered concept. There is no common and agreed understanding of how to offer and give feedback to achieve learning, besides the importance of stimulating self-refection. However, essential factors must be safeguarded to make feedback useful for learning. Simulation activity offers the participants a learning environment for training and developing feedback literacy. CRP seems to be a structure for debriefng that facilitates such training. How debriefng is structured and how the facilitator fosters such training are of great importance. Simulation is a resource-intensive learning approach, and in addition to achieving the given learning outcomes, emphasizing and utilizing such additional effects can make simulation activity an effective learning approach.

#### **References**

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

## **Learning Without a Teacher: Perceptions of Peer-to-Peer Learning Activities in Simulation Training**

Lise Degn, Hanne Selberg, and Anne-Lene Rye Markussen

#### **1 Introduction**

Over the past decades, higher education has been high on the political agenda. Almost all nations have seen an intense massifcation of higher education institutions and have focused on how best—and most effciently—to organize education. Peer-to-peer teaching, or more broadly peer learning, is one educational format that has been widely experimented with, i.e., students training each other and, in turn, themselves. One of its advantages is that it utilizes the students' own time and resources in the learning setting, thereby releasing the teacher's [1, 2].

Peer learning covers varying forms of interaction between students with learning in mind [1, 3], and pedagogical and didactic research and development highlight other benefts in addition to resource effciency and quality of education. Nursing education increasingly uses peer-to-peer-based simulation skills training in simulation labs [4, 5]. Both internationally and nationally, this development has been pushed by discussions about novice nurses lacking technical skills, partly due to decreased possibilities to practice skills during clinical placements [6]. Peer learning has been found applicable in development of technical skills and in preparing students for future practice in the clinical setting [4]. Health education research indicates that peer learning improves students' technical skills, enhances their confdence in skills performance, decreases anxiety [5, 7, 8], and enhances cooperative

L. Degn

Danish Centre for Studies in Research and Research Policy, Department of Political Science, Aarhus University, Aarhus, Denmark e-mail<EMAIL_ADDRESS>
H. Selberg (\*) · A.-L. R. Markussen Faculty of Health, Department of Nursing and Nutrition, University College Copenhagen, Copenhagen, Denmark e-mail<EMAIL_ADDRESS><EMAIL_ADDRESS>
<sup>©</sup> The Author(s) 2023

I. Akselbo, I. Aune (eds.), *How Can we Use Simulation to Improve Competencies in Nursing?*, https://doi.org/10.1007/978-3-031-10399-5\_7

learning, collaboration skills, knowledge sharing, and giving and seeking support [4, 9, 10].

The theoretical underpinning of peer-learning is sociocultural learning theory [11]. The assumption is that the learner never, or rarely, learns in a vacuum but is embedded in a social space and in interaction with others (teachers, peers, etc.). This social interaction can have both positive and negative implications, which the designer of a learning activity must take into account. Learning is also assumed to take place in both formal learning settings and informal contexts where individuals interact. A number of studies of nursing students conclude that peer learning may have a positive effect on learning outcome, for instance, because it helps prepare students become professional nurses through personal development and professional development [12].

Inspired by this research and based on our experience that students lack basic technical skills such as handling intravenous medication and oxygen therapy, the project, from which we are reporting in the present chapter, designed and set up "peer-to-peer self-learning stations" in order to give all students the opportunity to get hands-on skills training and to repeat the training for mastery learning. These self-learning stations were designed to train the basic skills that the students need to participate in complex full-scale scenarios and thus be able to concentrate on the overall learning goals.

In this chapter, we explore the strengths and weaknesses that nursing students highlight about peer-to-peer learning in simulation and discuss how these experiences and perceptions align with the theoretical expectations and assumptions. To explore this question, we report from an experimental study carried out at University College Copenhagen in Denmark. In the experiment, ffth-semester nursing students were subjected to an intensifed simulation intervention, combined with other supporting elements designed to increase collaborative and peer learning. One supporting element was a series of peer-to-peer sessions, in which small groups of students trained technical skills for mastery learning before engaging in full-scale scenarios. Traditionally, peer-to-peer activities are conducted with an experienced student tutoring less experienced peers. The intention in this experiment, however, was to enhance students' skills acquisition in a safe learning space by letting them practice at their own pace. The novelty of the approach was that it was designed to be "teacher-free," i.e., without a teacher present, thus allowing the students to take charge of their own learning, enhance engagement, and increase student confdence. This chapter therefore focuses on "teacher-free" learning, the students' expectations to this way of learning, and possible implications for the effect of peer learning activities.

In relation to the traditional teacher role, the role in simulation-based teaching changes markedly as the balance of power shifts from teacher to student. The student is expected to be responsible for own learning, and the teacher becomes the facilitator of learning rather than the transmitter of knowledge. Inspired by Hattie's [13] claim that the biggest effects on learning occur when students become their own teachers, the theory of self-conducted learning and fipped learning, we set up a peer-to-peer self-training concept with an instructional scaffolding.

The central research question we address in this chapter is: *How is peer-to-peer learning in simulation perceived by students, and what are the implications for the role of the teacher?*

#### **2 The Case**

To illuminate how students perceive peer-to-peer learning activities in simulation, we explore an experimental study of simulation-based training for nursing students in their ffth semester at University College Copenhagen in Denmark as part of the research project PIQUED (Pathways to Improve Quality in Higher Education). The control group of 155 students received "standard" simulation-based training in the ffth semester, which consists of three lessons of full-scale scenarios, whereas the intervention group (164 students) received a specially designed course, which ran over 3 full days in the ffth semester and 2 days in the sixth semester (Fig. 1).

In addition to receiving more simulation-based training, the intervention group had the opportunity to train specifc technical and non-technical skills repetitively with increasing complexity in specially designed simulation-based self-learning sessions, an element called peer-to-peer self-learning stations, which is the focus of this chapter. These sessions were intended to prepare the students to handle the interventions built into the complex full-scale scenarios at the end of the program. The assumption was that the intervention would increase the learning outcome, the technical competences, the feeling of self-effcacy, and the potential for transfer to clinical practice.

The peer-to-peer self-learning stations were designed to give the students the opportunity—in a simulation-based setup—to train technical skills in small groups to achieve mastery learning in the following skills: duodenal tube placement, peripheral intravenous cannulation, oxygen therapy, urinary catheterization, the

Trendelenburg position, intravenous medication administration, intravenous fuid therapy, and blood pressure measurement. The actions the students were expected to carry out follow the professional guidelines from VAR Healthcare [14]. The Model of Practical Skill Performance [15] forms the basis for the procedures in VAR Healthcare, and we have attached it to our didactical setup as it contains the categories that must be realized in a good performance of a practical nursing skills: substance, sequence, accuracy, fuency, integration, and caring comportment.

We focus on this particular element of the experiment (highlighted with the grey background in Fig. 1) and investigate how peer-to-peer learning can be integrated in simulation training of nursing students and what the potentials and pitfall may be. Since the focus of this chapter is solely on the potentials and pitfalls of peer-to-peer learning, and not in the effects of the experiment as such, the control group is not included in this particular study. For more information on the overall effects of the overall study, see Fuglsang et al. [17].

#### **2.1 Peer-to-Peer Self-Learning Stations**

The peer-to-peer self-learning stations used in the experiment consisted of a technology-assisted setup, which introduces and guides a group of 4–5 students through a learning exercise to train technical skills in a simulation environment (see Fig. 2). The learning exercise may involve mannequins, task trainers, and various remedies from clinical practice.

The underlying concept in the exercise is that the students are supposed to "act as if" they are treating a real patient which implies, for example, that in addition to the technical skills, they must guide the "patient."

While two students perform a procedure, observing students monitor scenarios and check off interventions using a tablet with a pre-determined set of biomarkers. The biomarkers are categorized in interventions before, during, and after execution of the procedure, e.g., "apply and tighten the tourniquet." The biomarkers are designed to track the participating students' concrete interventions while performing the procedures.

The training concept also allows for refection during training through refexive pop-up issues built into the program, e.g., "Where are you supposed to place the tourniquet in relation to the chosen insertion site?" The correct answer can be accessed after the refection. The rationale is that active evaluation, refection, and dialogue enhance learning for both evaluating and participating students. The session ends with student-led debriefng, where the participants receive automatic feedback on their execution of an action through the system, debrief with each other in the groups, and thereafter repeat the training and improve their performance. The learning exercise is thus highly scaffolded in order to avoid "erroneous learning" and thematic errors.

Training of technical skills at the peer-to-peer self-learning stations was conducted concurrently with training in non-technical skills, such as communication, teamwork, and algorithms. In the peer-to-peer self-learning sessions, the students worked independently, but teachers and teaching assistants involved in the project were present, primarily to observe collaboration in the groups and help with technical issues, e.g., equipment.

In the frst intervention round, the students worked in shifts at the stations over the 2 days to give everyone a turn as hands-on participant or observer. The second intervention round focused on repetition of selected technical and non-technical skills.

#### **3 Methods and Ethical Considerations**

The results presented in this chapter are derived from a survey study conducted at the end of each intervention round. The ethical considerations in relation to the overall project were assessed by the study board at the nursing education programme at University College Copenhagen, including considerations in relation to the balance between study benefts and human resources used, potential risks and inconveniences, methods, and participation. Even though participation in the simulation training was mandatory, the students were informed about the study and their right to refrain from participation by not flling in the surveys or actively participate in the simulation scenarios.

In a questionnaire with open-ended questions, the students were asked to describe their initial refections regarding four themes: (1) *peer-to-peer as a learning method*, (2) *collaboration with fellow students*, (3) *refection*, and (4) *learning outcome*. In the second round, a question about the use of a virtual task trainer for peripheral intravenous cannulation was added. The response rates were 93% in the frst round and 89% in the second.

Using a hermeneutic analysis [16], all answers were collated and sorted by the themes from both intervention rounds. At the frst stage of the analysis, the authors worked separately to identify statements and overall themes in the responses. At the second stage of the analysis, the authors worked together to develop the fnal categorizations. Finally, the statements and categories that related specifcally to the strengths and weaknesses of the learning method were identifed and condensed. The observation notes, produced by teachers and medical students, were used to validate the analytical observations and interpretations.

#### **4 Results**

In this section, we present the results of the analysis regarding the strengths and weaknesses of the peer-to-peer method as perceived by the students.

#### **4.1 Strengths of the Peer-to-Peer Method**

The analysis points to two central categories: *learning environment* and *collaboration and team dynamics.*

#### **4.1.1 The Learning Environment**

The learning environment was almost unanimously perceived as positive. As mentioned, the peer-to-peer self-learning stations were highly scaffolding to frame the learning experience as a safe learning space, where the students can make mistakes without consequences and learn through mistakes, correction, and refection. Exactly the opportunity to refect together is perceived as a strength by the students, as expressed here:

The refections we had after the sessions worked really well and resulted in the execution afterwards being more correct.1

The students perceive the interaction between the technical and the didactical setup positively, e.g., when they receive feedback directly through the Simpad as they are working. The students express that this gives them an insight into the status of their own competences, which are then strengthened through the ensuing dialogue with the other students. This forces them to express and argue for their actions, which is seen as a positive element in the learning experience.

Another element that is perceived as a strength of the peer-to-peer method is the opportunity to learn through mistakes and corrections. The students link this with their subsequent entry into "the real world" and describe that the peer-to-peer learning stations allow them to try out their skills "in reality, rather than just reading

<sup>1</sup>All quotes from students have been translated by the authors.

about it," while still being in an environment where mistakes are allowed and a part of the learning setup.

These descriptions indicate that the students have a clear sense of the progression in their educational program and that they link this progression to the individual elements in the program. They seem to understand the intention behind establishing a solid theoretical base before applying the theory in a controlled environment in the simulation and then fnally entering "the real world." The students describe this "real world" as their clinical training and as their future work as nurses. Learning outcome is thus coupled directly to practice, expressed as increased knowledge, experience, self-confdence, and motivation.

The students' responses after their clinical practice, i.e., when they return to the second round of peer-to-peer learning stations, show that this sense of progression is enduring. They note an increased sense of confdence and routine in relation to round one, and they note that fellow students may contribute with new refections.

#### **4.1.2 Collaboration and Team Dynamics**

The second positive category of the peer-to-peer learning format relates to the students' perceptions of *collaboration and team dynamics*. The collaborative selflearning stations very much rely on students learning from each other to support their motivation and learning outcome. The students seem to understand this design to some extent and perceive team collaboration as mainly positive. They describe a well-functioning group dynamic as a positive element of the learning situation and as something that increases their outcome, particularly as it helps create a conducive and safe learning atmosphere, where, e.g., mistakes are allowed. They especially highlight the collective refection that arises through the activities:

Good way to learn and get the procedures under your skin, with the opportunity to discuss doubts with peers = no stupid questions + fellow students can teach each other things that you might not know yourself, because everyone has different experiences.

The "lack" of a visible teacher is addressed, when a student describes how they "rather than asking the teacher, when we have doubts, we refect with each other." This is seen as a strength, as it provides the individual student with new perspectives and opportunities to discuss doubts with peers. The students are seen to contribute with various levels of knowledge and competences, and this creates a sense of security in the performance because they are able to collaborate on a common goal.

#### **4.2 Summary of Strengths**

In the analysis of the students' perceptions of strengths in the peer-to-peer learning format, the main element perceived as positive and conducive to learning is a safe learning environment, where the interplay between the technical and didactical setup helps the students refect on their own learning outcome and competences. Mistakes are allowed, the students help each other refect, and they seem to

understand the didactical setup of the activities and can connect them to their own progression and learning "path."

Interestingly, they do not mention the lack or absence of teachers as a strength, which indicates that even though they understand the didactical setup, the peer learning element is somewhat invisible to them. However, before elaborating on the absent teachers, let us frst look at the students' perceptions of weaknesses of peerto-peer learning.

#### **4.3 Weaknesses of the Peer-to-Peer Method**

The analysis points to two categories as central in the perception of weaknesses: *group dynamics* and *the understanding of learning*.

#### **4.3.1 Group Dynamics**

In the analysis of the strengths of peer-to-peer learning, it appears that the wellfunctioning team dynamic is perceived to be conducive to learning, but a malfunctioning group dynamic creates frustration, lack of motivation, and commitment, e.g., to complete the scenario. The students' descriptions of their experiences with teamwork in the peer-to-peer session center around "the other students" to a high degree. The commitment of the others may be seen as a precondition for the collaboration to be perceived as productive, and when this commitment is not present (or expressed), it is perceived as a problem. Several students highlight having been in a situation where the others "were not serious" about the learning exercise and describe this as detrimental to their own motivation.

A central point here is that the students' varying knowledge and competences may contribute to a productive common refection, but some students may perceive this as a weakness if individual contributions are not equal. Similarly, data demonstrates that students see it as a challenge to embrace "role play," which is so central to simulation, potentially because it is a collective exercise. The students describe it as diffcult to be serious about the role play and to "act as if," which is the central tenet of this type of learning activity.

One student says that role play is "diffcult to take seriously when we are just students," and another notes: "Fun to collaborate with fellow students, but diffcult to be serious about it and get into the roles."

#### **4.3.2 Students' Perception of Learning**

The second category, the students' understanding of learning, comprises statements about (not) understanding or recognizing certain activities as learning. This point is reinforced by responses from the second round, i.e., after clinical practice. The analysis demonstrates that the students' perception of peer-to-peer learning, and simulation generally, as a realistic space is challenged. Several students fnd it diffcult to embrace the situation when "it is not a real emergency" or fnd it "too artifcial to practice on a doll." This is seen in relation to the practice they have now encountered and been part of, and the discrepancy they experience between these two settings somehow disturbs their perception of the learning potential. Likewise, we see a number of statements about the perceived lack of relevance, again related to the "real world."

It becomes a bit frivolous with the doll, now that we are in clinical practice where we use it all day in the real world.

Yet, it is too unrealistic. It would be better earlier in the program. I get more out of experiencing it in clinical practice. First time was enough. This was repetition.

The relevance of simulation as a learning space also seems to diminish after the clinical practice, and the students have a clear picture of practice as "genuine" and simulation as a "copy," which is seen as less relevant after having met the real world. This is seen in statements about the students feeling "secure enough," i.e., having achieved the learning they need and that additional training is superfuous:

(it is) something one does every day for someone in clinical practice. Therefore not relevant or learning potential for me.

The analysis demonstrates that the students' approach to and understanding of learning are often not aligned with the elements characterizing peer-to-peer learning in simulation, e.g., learning through repetition, as shown above, or the prerequisite of bringing their own knowledge and competences to the table rather than being offered knowledge from a teacher.

Learning through repetition is sometimes seen as a strength and an element in creating a safe space, sometimes as unnecessary and meaningless. For example, the students grew tired of "doing the same role play four times. It is fne to train the procedure itself, but the role play was too much." In other words, repetition was not experienced as necessary to achieve security and confdence in a procedure but as demotivating and unnecessary. The same duality appears when looking at the responses from the second round, where repetition is both seen as an opportunity to train, e.g., sequences and strengthen security in the execution of procedures, and *also* as an unnecessary overfow of learning.

The lack of a teacher is another element of the learning setting where the analysis demonstrates a discrepancy between the students' perception of learning and the didactical setup. As mentioned, the didactical setup of the peer-to-peer self-learning station is based on the students learning together and from each other. However, they do not necessarily recognize this as a part of the didactics but as a faw in the setup. One student says:

It is a fne initiative, but very vague. We need more teachers to stand at each station, so we can talk and refect out loud and learn properly from it.

In general, the analysis suggests that they have a hard time accepting that there is no "right answer" but that the key learning outcome is in the process rather than the result. The responses tend to circle around the need to know whether what they are doing is "correct," and they seem to feel that they cannot fnd out without a teacher.

Some articulate a risk of "erroneous learning" or speak of uncertainty when there is no correct answer to the exercise.

Observation notes from the sessions support this by highlighting that the students mainly "request a teacher, when one is available—kind of just to be sure.

#### **4.4 Summary of Weaknesses**

In the analysis of the weaknesses, the students' expectations play a signifcant role in their perceptions of weaknesses. First, we have demonstrated that the students expect a great deal from their peers, and when these expectations are not met (lack of commitment etc.), the learning outcome suffers.

Likewise, the students progressively expect more from themselves and consequently from their education, and they are disappointed when they encounter "the same" exercises they now see as irrelevant.

This could all be understood in relation to the fnal category, namely, how the students understand learning, what learning is, and how it arises. To a large extent, the students expect learning to emanate from a teacher rather than in the process of peer interaction. They see the absence of a teacher, and consequently of a "right answer," as a weakness of the learning setup and fail to recognize the learning potential.

#### **5 Discussion**

In this chapter, we have explored the strengths and weaknesses of peer-to-peer learning identifed by students and discuss how their experiences and perceptions align with the theoretical expectations and assumptions. The quantitative effect measures of the overall study, i.e., the reported learning outcome of the whole experiment (peer-to-peer, full-scale simulation, and post-clinical practice followup; cf. Fig. 1), demonstrate that the students in the intervention group report markedly higher levels of professional self-confdence, particularly in their technical skills compared to non-technical skills [17], which is to a large extent attributable to the peer-to-peer learning sessions. However, the analysis of the students' descriptions of their experiences revealed additional interesting insights, particularly regarding their perceptions of learning and how they infuence their experiences of a "teacher-free" learning space.

Interestingly, it appears that the strengths of the peer-to-peer concept—strengths that the students to some extent recognize—are based on the premise *no teacher*, i.e., establishing a room for refection rather than testing, focus on strengthening teamwork, etc. One of the key weaknesses identifed by the students is the absence of a teacher. Observation notes suggest that when a teacher is present, the format is

compromised, as the students tend to seek confrmation that what they are doing is correct rather than refect with each other on what they are doing, which is a key learning goal of the exercise.

In other words, they seem to have an expectation that there is a "right answer" or a "right way of doing things" and that only the teacher has the answer. However, the idea behind this learning method is that the students hold the answer and that it emerges in their interactions. The analysis thereby reveals a mismatch between the students' expectations of *how to learn* and the learning concept of the exercise.

One possible explanation why the students experience this mismatch lies in the design of the learning exercise. As mentioned several times, the exercise is highly scaffolded, e.g., by technically assisted checklists, feedback, etc. The intention is to avoid erroneous learning and thematic errors, but it seems to reinforce the students' expectations of "a right answer" that lies with the teacher.

Additionally and related to the former point, the didactical idea behind the exercise seems to be somewhat invisible to the students, which may partially explain the mismatch between expectations and intentions. The students do recognize some benefts, i.e., the safe learning space with room to make mistakes, but fail to see others, i.e., the value of repetition and the learning potential in refecting with peers, indicating that they cannot see the connection between them. This is intertwined with the social interaction, which we see reinforcing these elements, both positively and negatively.

So where does this leave the teacher in the "teacher-free" learning space? Well, it seems that the teacher is still very much present through the design of the activity, and when the design is unclear or does not take social interaction suffciently into account, the teacher's absence becomes visible. This implies that the teacher's role in this kind of learning setting is much more important in the preparation phase and that explicitation of the didactical principles should play a greater role. In other words, the role of the teacher is perhaps to explain why they are not there rather than to attempt to be there "by proxy" through (excessive) scaffolding.

#### **6 Conclusion**

The central research question in this chapter was: *How is peer-to-peer learning in simulation perceived by students, and what are the implications for the role of the teacher?* The analysis indicates that peer-to-peer learning in simulation-based teaching has great potential. As mentioned in the discussion, the reported learning outcome of the whole experiment demonstrates markedly higher professional selfconfdence among students in the intervention group. However, the analysis and discussion also demonstrate that there is room for improvement, and the important lessons may be of great value to future peer-learning activities in simulation. The conclusion is that the peer-to-peer learning format entails a very different role for the teacher and that the explicitation of the didactical principles behind such exercises may enhance students' positive outcome.

**Acknowledgments** Laerdal Medical DK has facilitated the development of P2P scenarios. The contribution is gratefully acknowledged.

**Funding** This study is part of the PIQUED project (Pathways to Improve Quality in Higher Education). Funding from the Danish Ministry of Higher Education and Science is gratefully acknowledged.

#### **References**

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

## **Train the Trainer Course: How Can the Skills of a Facilitator Benefit Academic Staff in Nursing and Other Health Education Programs?**

Ulrika Eriksson and Astrid Kilvik

#### **1 Introduction**

In connection with the training of nurses and other health professionals, one has traditionally relied on active learning methods, such as simulation and skills training [1–3]. The purpose of such learning methods is to create arenas that resemble contexts and situations involving patients that the student will encounter in his/her professional life [4]. Particularly important for this learning method is the lecturer as facilitator with pedagogical responsibility [2]. The academic staff of nursing and other health professions have normally completed professional educations. The next educational stage consists of different types of formal higher education programs (master's degree and PhD programs), with or without a pedagogical foundation. Universities may also require documented and relevant practical and pedagogical skills (university pedagogy) in addition to the formal degree. With its emphasis on pedagogical content, a train the trainer course could subsequently represent a module that is part of a course in university pedagogy.

For lecturers who are responsible for the pedagogical and practical implementation of simulation exercises, it is important to have completed a facilitator course [7, 9]. According to Gardner, there are descriptions dating back to the 1980s of LOFT (Loft Oriented Flight Training) instructors, who relied on debriefng as a learning method [5]. The facilitator's skills in among other things debriefng signifcantly impact the student's possibilities for learning. In the words of Flatgård and Berg: "There are high demands on the competence and suitability of the facilitator, and it

U. Eriksson (\*)

Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway

e-mail<EMAIL_ADDRESS><EMAIL_ADDRESS>
A. Kilvik

Norwegian University of Science and Technology, University Library, Trondheim, Norway e-mail<EMAIL_ADDRESS>
I. Akselbo, I. Aune (eds.), *How Can we Use Simulation to Improve Competencies in Nursing?*, https://doi.org/10.1007/978-3-031-10399-5\_8

is crucial that there is a clear focus on systematic training, education and follow-up in this role" [6, p. 227].

Also important is the stress on standards of best practice in nursing. The skills of the facilitator are deemed to have a great impact on the learning of those taking part in a simulation exercise [7]. Further, it is crucial that organizations introduce systems that offer the facilitators the possibility of mentorship involving a senior facilitator [8, 9].

The thematic content of facilitator courses is normally not formalized in national or international steering documents [8]. However, this could vary between countries. Still, the exchange of knowledge and networking between various countries leaves an impression that there are similarities in the principles of implementation, with certain thematic and local adaptations. Usually, the courses do not yield credits from institutions of higher education. The courses tend to have a duration of 2–4 days. Among other things, they are based on pedagogical principles of adult learning, the different stages of simulation exercises, models of debriefng, the development of operationalized learning outcomes, and the role and function of the facilitator. Patient safety is a key factor. A common characteristic of such courses is the use of learning methods that require active participants [8]. This means that the participants carry out different forms of group work and take part in workshops while being able to acquire competence and skills in the role of facilitator in real simulation exercises. The competence is developed through the use of *feedback* and *feed forward* between participants and between participants and course facilitators. According to Hattie and Timperly [10], the concepts of *feedback* and *feed forward* can be described as follows:

Guided by this methodology, train the trainer courses rely on the same pedagogical principles as simulation exercises. The courses are organized by different institutions and organizations, such as Stavanger Acute Medicine Foundation for Education and Research (SAFER), network-based organizations like EuSim, The Medical Training and Simulation (METS) Center, or institutions linked to the health sector like Copenhagen Academy for Medical Education and Simulation (CAMES).

#### **2 Adult Learning and Train the Trainer Courses**

Train the trainer courses are based on a variety of learning theories and theoretical perspectives on how adults learn. Adult learning is a collective category denoting an academic feld that has evolved through decades and which draws inspiration from various disciplines and theoretical models. It is typically characterized by the use of the concept *adult learning* rather than the term *adult education* [11].

Generally, facilitator courses tend to emphasize perspectives on experiencebased learning, refection-on-action and refection-in-action, the use of *feed back* and *feed forward*, as well as the signifcance of the socio-cultural context [3, 12– 15]. By relying on learning tools that are typically used in relation to students in real simulation exercises, the facilitator will be able to become a professional facilitator of learning.

Through this approach to learning, the lecturer participating in a facilitator course will be joined by a student completing simulation exercises in a study programme [16]. The involvement of both parties will be based on the same understanding of adult learning.

Courses devoted to academic staff who wish to assume the function of facilitator are important when promoting learning among students of nursing and other health educations in general [8]. Still, only a limited number of institutions of higher education has formalized such courses for lecturers of nursing and other health sciences [11]. It has been argued that targeted courses in research method and pedagogy, like facilitator courses, are a condition for adult learning where simulation is part of the learning method [1, 6].

#### **3 Facilitator Versus Lecturer**

In higher education, the role of lecturers has over the decades developed from ensuring the transfer of information and knowledge toward a stronger emphasis on the role of a facilitator responsible for the students' learning processes. This is evident in the more frequent use of active learning methods, like simulation, skills training, team-based learning, problem-based learning, etc. This could be considered a paradigm shift where the lecturer more than ever before assumes the role of facilitator instead of a disseminator of facts, concepts, and information [17]. The latter understanding of the lecturer's role seems to emphasize a re-presentation of the curriculum in a study program, which is also possible for the students to access through self-studies. Even if the lecturer has articulated and disseminated the information, there is no guarantee that the student subsequently will be able to apply this information in his/her professional practice. This will obviously affect the ability to acquire action competence and preparedness in professional studies like nursing and other health sciences. A lecturer tends to have a more traditional approach to the profession, with the focus being more on the lecturer than on the learning student. The traditional lecturer has a clear-cut role or function, with a responsibility to present or share information about a given subject area or topic, as opposed to the facilitator [18].

The role of a facilitator stresses the conditions of adult learning through initiating and enabling discussion, refection, and in-depth learning in topics or subject areas that are defned in the steering documents of the study program [17, 19]. Fundamentally, the facilitator's role aims at promoting a methodological understanding where the student should *learn to learn.* It is crucial to lay the foundation for refection, independence, and the development of skills in cooperation, communication, and responsible action [20]. These focus areas are based on theoretical perspectives on learning, such as Kolb's learning cycle, Schøn's concepts of *refection-on-action and refection-in-action*, Lave and Wenger's emphasis on sociocultural context in communities of practice, as well as Dewey's theory of experience-based learning and *learning by doing* [20, 21]. These perspectives are described in more detail in the introductory chapter of this book.

A facilitator could also help raise the awareness about learning as a collective process that evolves and accumulates in interaction between people [20]. According to Tøsse [21, p. 91]: "The lecturer is a facilitator who in Maslow's words should help a person to be the best that he/she is able to become." A facilitating professional views learning rather as dialogue than pure dissemination of knowledge [21].

This is evident in the refection (debriefng) phase of simulation exercises, where the facilitator enters a dialogue with the students to refect on a concrete scenario related to the learning outcomes of the relevant activity [22]. Further, it is also important that the facilitator applies his/her skills to initiate transformative learning. Transformative learning is a type of learning where the students are made aware of their own opinions and mental habits. This typically takes place when the students discover that their opinions are not necessarily consistent with what has been implemented. Generally, transformative learning happens through refection that includes the emotional aspect of the learning process [20]. This form of learning is also described in social cognitive theory [20, 23].

A lecturer operating in the role of facilitator assists the students in their learning processes and thus helps cultivate new skills instead of assessing qualifcations. Skills development in relation to adult learning appears to be something different from what is traditionally associated with development of qualifcations. The term qualifcations is often seen in relation to a specifc position or function [24]. In higher education, the commonly applied concepts are knowledge, skills, and general competence [25]. This means that the lecturer in the role of a facilitator should pave the way for the learning of the individual student [19]. The facilitation skills of a lecturer may also help reduce the gap between theoretical and practical activities [26]. Healthcare Simulation Dictionary defnes the role and function of a facilitator like this:

*An individual who is involved in the implementation and/or delivery of simulation activities. For example, faculty, educators,* etc. *An individual that helps to bring about an outcome (such as learning, productivity, or communication) by providing indirect or unobtrusive assistance, guidance, or supervision. For example: The debriefng facilitator kept the discussion fowing smoothly*. [27, p. 18]*.*

#### **4 The Significance of Common Language and Framework**

In connection with simulation exercises, there is usually a framework underpinning the administrative and practical implementation, as well as the planning process. Administrative and practical considerations could, for instance, include selecting dates, room booking, access to adequate learning resources, etc. With regard to the planning of educational activities, important factors are scenario planning, choice of equipment, various learning tools and forms of simulation based on the learning outcomes, etc. [22].

As described earlier in this chapter, it is crucial that lecturers operating as facilitators have completed facilitation training courses [6]. It is also important that the content of the facilitator course corresponds to the standard of best practice, refected in the International Nursing Association of Clinical Simulation and Learning's (INACSL) Standards of Best Practice (Simulation Standard V: Facilitator):

*A profcient facilitator is required to manage the complexity of all aspects of simulation. The facilitator has specifc simulation education provided by forma coursework, continuing education offerings, and targeted work with an experienced mentor*. [9, p. S23].

The content of the facilitation training courses determines the administrative, practical, and academic decisions on which the simulation exercises in nursing and other health education programs are based. Lecturers who assume the role of facilitator at the end of the course would have different professional backgrounds and be at different stages in their careers. A train the trainer course that is specifcally designed for the facilitator role should be a comprehensive research-based and knowledge-oriented course based on the standard of best practice for professionals of nursing and other health educations. Just as the students enrolled in formal study programs, lecturers who strive to develop their skills through courses, such as the facilitator course, would require a so-called community of practice. The communities of practice could be described as follows: groups in which the participants share interests, problems, or ideas within an area and where they develop their competence through regular interaction and dialogue with each other. Communities of practice tend to be informally organized cooperative groups of learning. This does not mean that they are disorganized but rather that they are informal settings without reliance on traditional organizational control. The bond between the participants is based on their joint commitment, which in turn relies on the responsibility and effort to develop a common project. This commitment does not necessarily demand homogeneity and agreement. On the contrary, diversity is crucial in driving the cooperation forward [28]. Such a community of practice would promote learning from the course itself and the learning outcomes of the lecturers. In addition, the community will represent a counterbalance against the trend of individualization [19, 20].

Based on the different experiences among the lecturers involved in the course regarding active forms of learning, it is important to develop a learning process that takes these differences into consideration. This will affect the individual lecturer's ability to operate as an independent facilitator after completing the train the trainer course. It could be advisable to apply a structured framework, like Dreyfus and Dreyfus' competence steps, which take you from novice to advanced beginner, competent, profcient, and fnally expert. Through these steps, the lecturer in the new role as facilitator will be able to acquire competence [21]. This model represents a learning process which offers an opportunity: "...which takes you from a rule-based and context-dependent beginner's behaviour to an experience-based and context-independent expert behaviour" [21, p. 128]*.*

The learning outcomes and content of the train the trainer course make it possible to develop a common language and comprehensive perspective on adult learning, which is useful for other roles and functions as well. Development and the focus on a joint language could prevent the facilitation of simulation exercises from becoming arbitrary and individualized [19]. In this way, the students will encounter facilitators who, regardless of personal characteristics, has a focus on adult learning and active learning methods like skills training and simulation.

When developing simulation exercises, it is common to apply a structured, practical form of implementation, which normally and traditionally consists of a familiarization phase (briefng), an implementation phase, and a refection phase (debriefng) [29]. The facilitator course provides the lecturer with knowledge, skills, and general competence that should also beneft the student's learning. The mentioned framework enables an opportunity for learning.

#### **5 The Facilitator's Competence: Side Effects and Synergies**

The facilitation competence among lecturers of professional education could also involve some additional effects and synergies that ought to be highlighted. This could include educational leadership skills for those responsible for study programs or courses, development of new learning methods and forms of examination, support for colleagues through mentorship, and implementation of teamwork. Lecturers who have completed the train the trainer course should be in a good position to successfully implement simulation as a learning method in nursing and other health disciplines. Accordingly, the knowledge, skills, and competence of facilitation represent crucial components of educational leadership as a discipline [2]. This is relevant for lecturers with course responsibility or heads of studies, as well as advisors working with people in leadership positions. Obviously, it also applies to lecturersturned-facilitators who use student-focused approaches and learning tools that promote learning based on a useful design refecting the learning outcomes of the study program. One could be guided toward the learning tools required to achieve the learning outcomes of the course [18]. Lecturers with facilitation competence will be in a particularly good position to work on learning design in professional education.

The facilitation skills could also be useful when selecting forms of examination in nursing and other health disciplines. Toward the end of the study program, the student normally needs to go through a summative assessment, which is based on the requirements of society. The society needs to ensure that the individual student has acquired the necessary competence and obtain documentation in connection with admission to further studies. A lecturer with facilitator competence could in this context contribute to the development and implementation of examination forms that promote adult learning.

Examples of this are case-based written examinations or simulation-based forms of assessment. A facilitator has a stronger focus on student-centered learning than a social control system, representing a counterweight against traditional examination forms (school examinations) and a new approach toward adult learning [19].

In nursing and other health disciplines, there has been a tendency to put more emphasis on the phenomenon of teamwork, which is in line with the focus on general quality and patient safety in the health services [30]. Simulation as a learning method is well suited to develop competence and skills in teamwork [3]. As mentioned earlier, lecturers with facilitator competence could give valuable contributions to the implementation of team-based learning in different study programs. These contributions may be refected in the steering documents of a specifc course, or more generally in the study program through implementation and development of simulation exercises [31].

In higher education, there is a growing need to establish a system that enables facilitators to receive mentorship from, for instance, senior facilitators [8, 9]. By systematically applying a system of mentorship, as a form of inter-colleague support, lecturers will be able to receive *feedback* and *feed forward*, in the same way as the students. According to de Lange and Lauvås [32], colleague support is a form of supervision that involves professionals at the same educational level. In this context, a mentorship system where the facilitation skills are applied in relation to colleagues can be defned as a form of colleague support. As mentioned above, the concepts of *feedback* and *feed forward* are useful [10]. An example of this could be a situation where de-briefng takes place following a simulation exercise, where a senior facilitator has participated as an observer. The following questions and statements could be natural in a conversation between a mentor and his/her colleague:

This is a systematic, simple, and concrete structure that could enable adult learning [33]. The contribution of the senior facilitator is to combine experiences with the possibilities for transformation. This makes it possible to use facilitation skills to create positive side effects for the learning party and also discover useful synergies in the lecturer's daily work. *Feedback* and *feed forward* ought to be seen as benefcial for all learning [33], and the signifcance of colleague support has already been thoroughly described in the literature [32].

The abovementioned colleague support, through a system of mentorship where facilitation skills are used, should be viewed in relation to the concept of lifelong learning. Lifelong learning may happen through both formal and informal learning and represents a form of strategy for all types of education, as well as learning in professional life and life in general. Lifelong learning is thus a natural component in the concept of adult learning [34].

The competence acquired through facilitation, among other things, is also transferable to other contexts of learning in higher education. Examples of this can be supervision of theoretical student work, conversations with students who experience challenges in their studies (advisory conversations), or formative assessment in connection with clinical practice. According to Wahlgren [35], a lecturer working in higher education should be able to assume different roles and develop skills in various contexts. A lecturer with facilitation competence ought to be able to perform such a role and use the skills that Wahlgren considers necessary for a supervisor and coach. The mentioned roles are particularly important when promoting adult learning [35]. How facilitation skills could beneft lecturers with years of professional experience has not been clearly highlighted in the literature. But one could well assume that facilitation competence represents a contribution to a more studentcentered understanding of learning.

#### **6 Conclusion**

The facilitator has a key function in simulation exercises for students in nursing and other health disciplines, given his/her responsibility for enabling successful learning processes. The skills of the facilitator are therefore critically important in enabling the learning of the students. This competence is available through train the trainer courses, which are based on the principles of simulation as a learning method and rely on theoretical perspectives on adult learning.

A systematic train the trainer course could help the facilitator achieve professional confdence and a solid foundation for implementing his/her particular role. The framework, content, and learning outcomes of the facilitator course have helped create a common language and a comprehensive perspective on adult learning. This will ensure that students encounter a facilitator who relies on *context-independent expert behavior* instead of an arbitrary and individualized role.

Generally, the facilitator tends to rather emphasize his/her role as an active *enabler* of student learning than an instrumental function of *conveyor* of facts, concepts, and pure information. This separates a facilitator from a lecturer. Moreover, the facilitation skills among lecturers of nursing and other health disciplines could yield additional effects and synergies that are useful in their general professional lives. Facilitation skills could be applied in all types of educational leadership, in the development of learning design, and when selecting between different forms of examination. With facilitation skills, lecturers could also help cultivate competence related to teamwork. Another additional effect is the possibility of using the mentorship system of the train the trainer course, with senior facilitators providing support for colleagues at the same professional level. The roles of coach and supervisor, which are developed through the train the trainer course, may also be applied vis-àvis students, for instance, in connection with advisory conversations or formative assessments in clinical practice.

The ability to alternate between roles in different situations and contexts is signifcant when promoting adult learning. The focus of the train the trainer course with regard to student activity and lifelong learning can be transferred to other learning situations. Even if the importance of facilitation skills is not strongly emphasized in the literature, it is fair to assume that this competence will help promote a more student-centered learning perspective among lecturers of nursing and other health professions.

#### **References**

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

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**Playful Learning with VR-SIMI Model: The Use of 360-Video as a Learning Tool for Nursing Students in a Psychiatric Simulation Setting**

Siri Haugan, Eivind Kværnø, Johnny Sandaker, Jonas Langset Hustad, and Gunnar Orn Thordarson

#### **1 Introduction**

The development of new technologies has become more apparent over the last decade, especially with the development of mobile platforms (laptops, tablets, mobile phones), all of which connect to the Internet. How and whether technology improves learning are two big questions and the source of much debate. In this chapter, the authors will look at how the use of 360-degree videos, viewed through head-mounted displays (virtual reality headsets or HMDs), can become supplements to high-fdelity simulations using similar pedagogy. The role of 360-degree video in education is not yet clearly identifed and understood, as little research has been done on this topic [1].

Since the introduction of the blackboard within education in the early eighteenth century, the development of technologies used in education has been many: overhead projectors, whiteboards, computers, and tablets, to mention a few. People more generally are faced with new opportunities that enable us to interact with anyone anywhere in the world, at any time; we can access any information through the touch of a button. These changes have occurred rapidly and affect how teaching and learning is viewed. How has this affected learning? The students themselves are

S. Haugan (\*) · E. Kværnø

Department for Public Health and Nursing, NTNU, Trondheim, Norway e-mail<EMAIL_ADDRESS><EMAIL_ADDRESS>
J. Sandaker

Center for Simulation and Innovation SIMInnlandet, Innlandet Hospital Trust, Ottestad, Norway e-mail<EMAIL_ADDRESS>
J. L. Hustad · G. O. Thordarson

Department for Learning Support, NTNU, Trondheim, Norway e-mail<EMAIL_ADDRESS><EMAIL_ADDRESS>
I. Akselbo, I. Aune (eds.), *How Can we Use Simulation to Improve Competencies in Nursing?*, https://doi.org/10.1007/978-3-031-10399-5\_9

now able to access information traditionally provided by the instructor and textbooks [2].

A bachelor's degree in nursing must change in-step with new knowledge and new methods of learning. Students in the future may not have the same relationship to books as the previous generation but will perhaps have acquired other methods of gaining knowledge. Students now have a world of knowledge literally at the tip of their fngers and face the challenge of fltering the information to determine what is accurate. Teachers today aim to develop new didactical methods where students can focus on interpersonal interactions, especially in meetings with patients where they can practice professional relationship skills [3]. It is in encounters with patients that relational skills become evident. The authors believe that videos showing relevant scenarios in a 360-degree video format will be benefcial for students preparing for the clinical setting. Practice in mental health work can challenge students, as the practice brings with it new situations and unknown human encounters, which are often in combination with misguided assumptions about mental health issues [4].

Using VR technology in healthcare training is an important supplement when creating training and simulation programs [5]. It has become common in recent years to use 360-degree videos when creating relevant clinical settings and training. Themes with challenging topics such as suicide assessment, managing violence and threats, and the opportunities to train in demanding interpersonal situations are limited in healthcare simulation training [6]. Research in the feld suggests that if we are affected emotionally, we learn better. With VR glasses, senses and emotions are activated, enabling students to learn in a completely different way than by reading or listening to a lecture [7]. Nursing requires creativity and a good ability for clinical decision-making processes. To practice this, playfulness can give students motivation and the opportunity to promote learning. 360-Degree video can be seen as a playful way to learn from new situations. "Play" in particular has the ability to unite imagination and intellect in that it acts as a tool for students to discover things at their own pace and in their own way [8]. Playful learning increases the levels of oxytocin, engages the students emotionally, and gives them a creative experience [9].

#### **2 Technical Aspects of 360-Degree Video in Education**

Virtual reality as a concept has acquired distinct meanings. The history began long before computers and modern technologies were invented. In the 1930s, the term "virtual reality" was frst used by the French writer and philosopher Antonin Artaud in his book *The Theatre and Its Double* [10] when he tried to construct the illusion of being in other spaces [11]. The American inventor and flm enthusiast Morton Heilig is perhaps the best known of these VR experimenters. He experimented with a project called multisensory theatre. In this performance, he used three-dimensional images imposed on physical facilities such as smell, wind, and movement. In 1962, he built a prototype of his vision called Sensorama Simulator [12]. In modern times, Heilig has been called the father of virtual reality (VR) technology. A few

years later, in 1965, Ivan Sutherland and his students Danny Cohen, among others, constructed the frst device that could be placed on the head, the head-mounted display (HMD), with head-tracking and stereoscopic glasses. The surroundings were updated in the glasses that also took into account the head position and direction [1].

Up until the 2000s, new phones and boards with higher resolution and motion detection were produced, as well as new types of headsets that made it possible to participate in simulations through VR headsets. This complete presence is often described as an immersive state [13]. Over the past 20 years, VR technology has been further developed in computer games, cars, and fight simulator training programs. In the mid-2010s and beyond, VR became more recognized as technology in educational research environments as well as in industry, military, and architecture. The concept of immersive learning was introduced and became more accessible with a new stand-alone headset in 2013. Within VR simulation, as in regular healthcare simulation with technical skills training on procedures, it is of great importance that the training takes place in a physical safe environment to prevent injury [14]. Over time, programmes have been developed to train technical skills (TS) on procedures in healthcare and in industrial enterprises. Immersive VR simulation with HMDs has been used since the early 2000s [13]. Today, VR technology has reached a point of technological maturity that makes it more accessible for both the consumer market and educational institutions [15].

Videos tell their stories through an established language of cinema, using certain cues that the audience interprets [16]. However, 360-degree video is a relatively new experience to most people; only about 19% of US adults had tried VR in 2020 [15]. This means that the language of storytelling is not as established in this medium, and this must be considered when designing the 360-degree video. In a non-360 degree video, the director has full control of the audience's attention: where they should focus and how they should experience the story being told. This is not the case with 360-degree videos as the user is in control of what they view in every moment. Creators need to design an engaging clinical situation where the student is guided, through visual and auditorial cues, to focus on the most relevant elements in order to learn [17].

Another aspect of student lack of experience with VR is the technical threshold that the HMDs present. The student will have a reduced experience if they do not know how to adjust them to their needs, for example, by adjusting the straps, volume, and focus. The technical frustration will be lessened with time as more students test them out and learn how to get the most out of them [18], but for now, ample time to introduce and explain the equipment to new users is recommended.

A great beneft to 360-degree video is the possibility of centralized distribution of produced content. Each produced simulation can be digitally distributed to any HMD. The more students that can use the same 360-degree video, the less the median cost of each produced experience. This allows institutions to work together on development and production and then share the fnal product. Maintenance on VR labs with self-contained HMDs involves keeping the HMD operational and replacing erroneous units.

#### **3 Research on Virtual Reality and 360-Degree Video**

VR for educational purposes has been researched for decades [12], with many compelling fndings. The research on 360-degree video in education, however, seems to still be in an early exploratory phase [1], perhaps owing to only-recently dropping costs for the necessary technology. In this section, we will briefy discuss some fndings of research on both topics to explore how the use of 360-degree video might beneft nursing simulation.

First, a note on the technical differences between 360-degree video and VR. Whereas VR puts the viewer in a virtual 3D-modeled environment, the environment of a 360-degree video is pre-recorded using a special camera that flms in every direction. This means that the viewer can look around freely as in other VR experiences, but movement is limited because the camera only records from one position at a time, and interaction is limited because the environment is pre-recorded. Even so, 360-degree video is often referred to as VR [12], and some of the possible experiences of VR can be achieved using 360-degree video.

When researchers discuss the benefts of VR, they often highlight its ability to make the participant feel as if she is really present in a situation, the illusion of "presence," rather than viewing the situation as a distanced observer [12]. This effect is apparent in many different VR experiments. For example, participants have been shown to feel pain and discomfort when their virtual body is subjected to certain stimuli [19], participants react to virtual characters with the same social instincts for personal distance as if they were real people [13] and, perhaps most importantly, participants themselves often report an experience of virtual presence [12].

This effect has been utilized in different ways that might prove useful for nursing simulation. Pan and Slater (2011) used VR to simulate ethical dilemmas and found that participants would sometimes respond differently to the dilemma after having experienced it virtually, rather than just as a theoretical problem [20]. Kleinsmith et al. found that VR could be used as empathy training with virtual patients [21], and Cook et al. concludes that VR can "provide training and many different scenarios that will help [doctors] toward gaining experience" [14]. Virtual experiences have also been shown to reduce anxiety from real experiences, for example, in VR-based exposure therapy for people suffering from arachnophobia [22].

The experience of "presence" can also involve being in a different body, which opens up whole new avenues of possibilities.  Ahn et al. let participants with normal vision virtually experience different forms of colour blindness, leading to more helpful behaviour toward people with colour blindness as compared to a control group [24]. VR is a promising tool for learning goals that are concerned with empathy, experience, and ethics.

Some Korean universities tested VR specifcally in nursing education as a safe alternative to clinical practice during the COVID-19 pandemic. They found that VR, in combination with traditional simulation, gave the best learning results and highlighted the importance of a framework of learning activities before and after the VR session [25].

But do these fndings translate to the use of 360-degree video? As mentioned, these technologies have fundamental differences, as well as similarities. In a scoping review of the research on 360-degree video, Snelson and Hsu found that an experience of "presence" was common among participants in experiments involving 360-degree video [1]. Virtual exposure therapy has also proven successful using 360-degree video [26], hinting that exposure to stressful nursing-related situations in 360-degree video might lead to reduced stress in real clinical situations. Overall, Snelson and Hsu found mixed results for the learning benefts of 360-degree video but noted that "there is some indication that learning with 360-degree VR video might be more appropriate for certain types of learning such as promoting empathy, refection, or skill-based knowledge as opposed to factual or conceptual knowledge" [1]. These types of learning are a good ft with the goals of nursing simulation.

#### **4 Preparing for Psychiatric Nursing**

Students who are preparing for practice within psychiatric nursing must be able to meet patients who are struggling with depression, extensive anxiety problems, psychoses, substance abuse disorders, and, potentially, an inability to self-care [27]. Nursing students must learn to deal with a feld that is at times complex, which requires a dynamic approach. In the face of mental health work, one can see how health professionals become emotionally involved in patient's diffculties. Interaction with the patients may trigger adverse interactions such as rejection, quarrelling, neglect, and opposition. In order to maintain a professional relationship, nursing students are required to accept, validate, and use communication skills to promote health [27]. Nursing students are taught various techniques for communication, such as active listening, and affrmative and exploratory skills. Practicing mentalization, seeing others from the inside and yourself from the outside, is one such method. Mentalization as a perspective is universal and can be used in many types of consultations with patients [5]. It is, however, diffcult to prepare for the complex, unique, and delicate nature of each meeting, as each interaction involves complex, subtle verbal and nonverbal cues [28, 29]. Simulation is a pedagogical method that has been used to prepare students for patient interactions, which enables students to put already-acquired skills and knowledge to use in a setting that is as close to reality as possible. This provides students with valuable experience and knowledge into how their own reactions may infuence their situational awareness [3, 4].

Students in nursing are trained in knowledge-based practice. This requires making assessments based on both research, experience, and promoting shared decisions, which requires unbiased assessment [30]. Students must be able to meet demanding clinical situations in a tactful way. It is an advantage if students have emotionally trained for this, which 360-degree video offers. Being able to identify where there is a lack of knowledge by mapping current knowledge is important. How these challenges are met and how capability and fexibility are shown to integrate new with existing knowledge are key prerequisites for knowledge advancement [31].

#### **5 Why Is 360-Degree Video Suitable for Promoting Nursing Students' Competence in Psychiatric Nursing?**

The pedagogy of simulation aims to create a safe environment for refection and learning, enabling the students to apply already acquired skills, knowledge, and values in a clinical setting. Simulation has traditionally been an arena where the student is able to combine technical skills and non-technical skills (communication, teamwork, decision-making, and critical thinking) [32–34]. Simulation utilizes a combination of pedagogy and technology to achieve the desired learning outcome, which is covered in other sections.

Skills training has been a part of nursing education since 1910 [34], when the frst lifelike mannequin was developed for nurses to practice their clinical skills. It was a doll with no other functions, which can be defned as a low-fdelity simulator. Since then, the technology has made leaps. Today's modern mannequins can give clinical signs and symptoms as well as talk. These mannequins are expensive and are regarded as high-fdelity simulators [32, 34].

Clinical simulation in a somatic setting has the unique ability to imitate real-life scenarios, as mannequins can give clinical signs and symptoms. Students act on the clinical signs and symptoms and get real-time feedback from their interventions. However, the nature of the psychiatric setting, where one or two nurses are faced with conversations of a delicate or volatile nature, makes it exceedingly diffcult to use mannequins [3, 28]. Mannequins lack the ability to provide the complex nonverbal cues, such as facial expression, eye movement, and body posture, which are all important aspects in communication. The learning outcomes in simulations within the psychiatric setting might address how the nursing student or nurse applies specifc mental health tools to assess for suicide risk, depression, or symptoms of other illnesses.

Nursing is a profession where skills, knowledge, and experience, combined with professional attitudes and values, play crucial parts. Nursing students need to make the journey form novice to clinician over a period of 3 years. Students must develop skills within the psychomotor, cognitive, and affective domain. The psychomotor and cognitive domains may be covered through several didactive methods such as PBL (problem-based learning) and TBL (team-based learning) [35, 36]. Although student active methods, like those mentioned above, address the psychomotor and cognitive domains, the affective domain "remains undiscovered country" [37]. The affective domain addresses the students' perspectives, emotions, feelings, and attitudes that the student needs to be able to understand the motivation for action and inaction [38].

In the reality of clinical life, students are faced with the complexity of applying already-acquired clinical skills and knowledge in real-life situations. Although there is a growing body of research addressing student awareness of their own feelings, the challenge is how this is transferred to students [3]. Students who are preparing for clinical placements in the psychiatric setting need to be aware of the sensitive, unpredictable, and sometime volatile nature of this part of nursing. By experiencing certain scenarios, students may start to develop new awareness and a deeper understanding of how they may interact with the patients [33].

For simulations in the psychiatric setting, actors may be used to imitate a patient, which provides students with valuable interaction and experience. It does, however, require the actor to be provided with suffcient direction. The task of the actor is not to act for the students but with the students to such an extent that they are able to address the learning outcome. Some simulation centres employ trained actors, while others use other unskilled actors. If the actor overplays or is unable to understand the desired learning outcome, the whole simulation experience might be affected. Although the use of 360-degree video lacks the interaction that high-fdelity simulations have, it has the advantage that by using 360-degree video, the quality of the recording and the actor can be controlled giving a consistency to the learning outcomes. Few studies [3, 29] have been done on the use of 360-degree video in this type of setting, but this method has the possibility of creating a private room environment free from distractions. This method provides an opportunity to refect openly and equally without concern for other participants, as the students have one common experience, though different perceptions. Furthermore, this differs from an experience on a fat screen, as the participant is immersed, but not by environmental distractions like other electronic devices, noise, light, and/or other factors [39].

The types of skills nurses need in the psychiatric clinic is complex and should not be reduced to communication skills. Anderson and colleagues have operationalized a set of facilitative interpersonal skills that are meaningful and useful [40]. These skills are used by helpers in various professions and are believed to motivate a person with emotional or mental diffculties to initiate change toward better emotional and mental health. The core of facilitating interpersonal skills can be defned by the fact that the helper, i.e. nurse, is able to capture, understand, and communicate a wide range of interpersonal messages to a person seeking help. The nurse can then convince the person seeking help to adopt proposed solutions to the problem and let go of more inappropriate coping strategies [40]. How one learns these skills is often based on both practical and theoretical knowledge. Mass training becomes possible with the use of 360-degree video, which constructs a form of experiential knowledge.

#### **6 VR-360-Degree Model: "VR-SIMI Model"**

VR-SIMI is a model used to describe a specifc VR-training method for health professionals developed at the Centre for Simulation and Innovation at SIMInnlandet, Innlandet Hospital Trust in Norway [41]. The terms used at SIMInnlandet, to describe the specifc stages of the method, are *Briefng, E-Motion*, and *Debriefng* as shown in Fig. 1*.*

The VR-SIMI model combines pedagogical principles from medical simulation with the 360-degree VR scenarios, exposing and preparing health professionals for clinical situations in the psychiatric nursing setting, by training their ability to refect on and learn from relevant situations. Figure 2 shows examples of situations that students can practice increasing their competence in psychiatric

Concerns about child welfare

nursing. VR-SIMI involves embodied multimodal learning by offering theoretical knowledge, immersive 360-degree video experience, and refection in the same exercise.

Psychological safety is based on trust and will help students reduce their interpersonal risk. This will promote certainty and a will to change in the next phase [42]. Psychological safety can be seen as a strategy which helps people overcome their defensiveness or learning anxiety. Schein argues that psychological safety allows people to focus on collective goals and problem prevention, rather than on self-protection. We can see this in the light of the use of 360-degree video as a tool that allows the students to be free without defence and self-focus [43].

E-motion describes the student viewing experience and refers to the feeling of "presence," as discussed in the previous section [7].

#### **6.1 Briefing**

In VR-SIMI, psychological safety is of great importance for the training experience. The building blocks for a "safe room" are laid in the pre-simulation phase. In addition to establishing a fat group structure through the "sharing is caring" attitude, factors such as clarifying expectations, closeness to the collaborative exploration of the theoretical input and learning outcomes. The friendly fostering of diversity is important in VR-SIMI to ensure the psychological safety for the participants. Maintaining a psychologically and physically safe learning environment is crucial for the student experience. It is therefore important that the number of participants experiencing the scenario does not exceed ten students. This enables all students to actively participate in the debriefng and may reduce a fear of feeling exposed. In

the pilot stages of the VR-SIMI experience, some students experience dizziness and nausea, which can result in students falling over. Students expressed feeling safer when sitting down in an offce chair with arm rests equipped with a swiveling option (e.g. gaming chairs). The briefng phase ensures the theoretical and emotional warm-up through the presentation of the model, the technology, learning goals, and theory relevant to the learning goals. Furthermore, the participants are invited to share and contribute with their own knowledge and experience from their education and work as healthcare professionals.

#### **6.2 E-Motion Phase: 360-Degree VR Experience**

During this phase, students put on the HMDs, as can be seen in Picture 1. The facilitator conducts a "start-up ritual," making sure equipment is ready. The facilitator then starts the scenario simultaneously on all HMDs. Though all students watch the same recording, the experience will depend on each participant's personal and professional values, as well as lived experience. The subjective experience of each individual participant may therefore vary considerably, which creates the foundation for refection and learning. The group takes this diversity of embodied experiences into the refection phase. Ideally, the facilitator participates in the VR experience.

**Picture 1** A VR simulation group carrying out the 360-degree VR experience viewed through head-mounted displays, in the E-Motion phase. (*Photo: Marius Huse*)

#### **6.3 Debriefing–Reflection Phase**

In addition to opening to the participants' bodily experiences, thoughts, and feelings related to the virtual scenario, the consideration of diversity among the participants is of importance. A variety of experiences and perspectives within the group after the same VR-scenario is of special interest. The facilitator encourages the students to be active participants throughout this phase, emphasizing the process of refection, rather than right or wrong answers. The importance of the refection process has been covered earlier in this book.

#### **6.4 Exercises**

The VR-SIMI model was used in a project called "VR-SIMI Acute" that included four exercises with playful learning in mind. The group members viewed the same VR-experience with the following frames:

In exercise 1, the staff work on the understanding of mental illness and how it affects them. This exercise challenges perceptions and aims to increase knowledge of student's own understanding and awareness. In exercises 2 and 3, participants work on the theoretical perspective mentalization and how this can function as a good scenario for improving relations skills.

Mentalizing is the capacity to understand ourselves and others in terms of intentional mental states, such as feelings, desires, wishes, attitudes, and goals. It is a fundamental capacity in our social environment: Without this capacity, we would be completely lost in a world that is determined by complex and ever-changing interpersonal relationships that require a high degree of collaboration and mutual understanding [44, p. 366].

When students work to see themselves from the outside and others from the inside, relational competence will increase, especially through an increased awareness of how complicated but also important relational compassion is. Exercise 4 titled "Change Glasses" challenges perspectives on student's own and others' roles and aims to increase understanding for others in order to prevent misunderstandings.

#### **6.5 Potential Clinical Situations: Suitable as Preparation for Clinical Practice**

A nurse is committed to promoting hope and change in the case of creating healthpromoting behaviours [45], among many relational skills, some of which are mentioned here in the chapter. How nursing students can pass on and create empathy in interactions with the patient is dependent on the nurses' professional attitudes and clinical experience. A nursing student naturally lacks clinical experience and certain types of training that a nurse needs to and wants to practice. It is not unknown for nursing students to meet patients who have complex health challenges [30]. VR simulations are refective of clinical situations in psychiatric nursing and give possibilities for practice.

#### **7 Conclusions**

By looking for new methods that can be used in educational institutions, we can elevate students' perspective and activation so that learning is formed, especially learning that is needed for the specifc felds in the clinic. The potential of 360-degree VR video gives fexibility to create systematic experiential learning as well as playful emotional learning in collaboration with students. This chapter has provided knowledge about the practical use of 360-degree VR video, technical potential, and challenges. We have also discussed why this method is suitable for improving nursing students' competence in the psychiatric clinic. The chapter is an introduction to inspire use of 360-degree VR video in professional education, with a focus on nursing education. 360-Degree video simulations will not replace real-life situations but can act as a complement. What 360-degree video simulation offers is a tool that allows nursing students to have increased time in relevant situations that can contribute to quicker and better decision-making in real, clinical situations. This chapter argues that using 360-degree video creates a playful and safe learning environment, promoting refection and learning. The VR- SIMI model shows more explicitly how 360-degree VR video can be used as a tool for nursing students in a psychiatric simulation. The 360-degree VR simulation of a clinical situation is a highly immersive experience and gives the participants a feeling of "being there," a feeling of presence.

#### **References**

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

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## **Virtual Reality (VR) in Anatomy Teaching and Learning in Higher Healthcare Education**

K. Aasekjær, B. Gjesdal, I. Rosenberg, and L. P. Bovim

#### **1 Introduction**

The implementation and use of technology is not a new phenomenon in higher education, as the use of technology creates new possibilities and challenges involving pedagogical thinking and planning [1]. Since learning using digital technology can provide a wider variation within education, as well as training for a professional career, society in general increasingly implements and adopts new technology [1, 2]. The use of technology can enhance interest among students and provide them with better conditions to understand complex information and phenomena [1].

The quality of healthcare and patient safety is prioritized within the healthcare system, and evidence-based health education is important when it comes to ensuring quality of care and patient safety [3]. Clinical practice is in a state of continuous change and has led to increasing demands in terms of student competencies and clinical skills. Higher education plays an important role in knowledge translation and in strengthening the competencies and clinical skills of students [4]. In higher education, the implementation of technology has enhanced the possibilities to teach students more complex concepts in a more effcient manner and with greater variation and visualization [5]. An example of a complex subject is the teaching and learning of anatomy. Anatomy is considered an essential science within medicine

Faculty of Health and Social Sciences, Western University of Applied Science, Bergen, Norway

K. Aasekjær (\*) · B. Gjesdal · I. Rosenberg

e-mail<EMAIL_ADDRESS><EMAIL_ADDRESS><EMAIL_ADDRESS><EMAIL_ADDRESS>
L. P. Bovim

Faculty of Health and Social Sciences, Western University of Applied Science, Bergen, Norway

Haukeland University Hospital, Energy Centre, Bergen, Norway e-mail<EMAIL_ADDRESS>
I. Akselbo, I. Aune (eds.), *How Can we Use Simulation to Improve Competencies in Nursing?*, https://doi.org/10.1007/978-3-031-10399-5\_10

and healthcare education, and anatomical knowledge is important for developing skills and becoming a competent practitioner [5–8].

Anatomy is a visual and three-dimensional (3D) science, traditionally taught in higher education through two-dimensional presentations (pictures) in books and classroom teaching. A recognized visualization technology for exploring and experiencing 3D is virtual reality (VR). Numerous systematic reviews state that technology such as VR can enhance motivation for learning and preserve knowledge and in-depth learning [9–13]. This chapter provides a general introduction to different aspects of VR and its potential relevance for increasing the quality of anatomy teaching and learning in higher education. We also provide practical insights into the development and implementation of VR-based teaching and learning of anatomy on the bachelor and master's levels in a Norwegian setting.

#### **2 Virtual Reality: The "Whats" and "Whys"**

VR is defned as "a technology which allows a user to interact with a computersimulated environment, be it a real or imagined one" [14] and is increasingly presented as a feasible interface to promote salient, motivational, and safe environments for virtual learning [15, 16]. However, the defnition of VR varies signifcantly in scientifc literature and covers a wide range of technologies. In short, it varies from the classic, non-immersive desktop system (PC, Mac®, PlayStation®) with or without added motion tracking (Nintendo Wii® and Microsoft Kinect®) to immersive CAVE systems (multiple large projected surfaces) and head-mounted display (HMD) systems (HTC Vive® and Oculus Rift®) [17] (Fig. 1). CAVE systems have become more common due to technological advances and a desire to prioritize such systems [17]. However, our focus in this chapter is on the use of head-mounted display (HMD) systems. With HMDs, the user is immersed in the virtual environment by wearing goggles with screens for both eyes. The goggles utilize sensors that give the software exact information on the user's position and movement. Headmounted display (HMD) systems have an additional advantage over less immersive

**Fig. 1** Examples of three different types of virtual reality systems: desktop, CAVE, and headmounted display. (Illustration: Lauritz Valved)

VR technologies in that they give students the possibility to physically move around in the environment and interact with, explore, and move objects from different angles.

Immersion relates to how effectively the computer-simulated environment replaces the perception of the real world, making the student perceive the environment through sensorimotor contingencies [18], meaning that the student's learning is shaped by stimuli and actions within the virtual environment. In this setting, it is of relevance to note the difference between 360-photo and video-based virtual experiences and computer-generated VR environments (virtual environments, VE). A photo or video captured by a 360-degree camera can be viewed in a head-mounted display (HMD) system and enables the student to visually explore the surroundings. However, this exploration is limited to the point in space in which the camera is positioned at the time of capture and the timeline of events and interactions is predefned. A virtual environment is based on 3D models, and the head-mounted display (HMD) system's position and movements are translated into the virtual environment, thus enabling the student to move around in this environment, viewing the surroundings from all positions and angles. In a VE, the timeline of events and interactions is not necessarily predefned, as the 3D models can be generated for continuous interaction.