We sought reported factors that contribute to the optimisation of learning in the observer role. It is clear from this review that the use of observer tools to focus the observer and role clarity are strongly associated with role satisfaction and learning outcomes in observer roles. This finding is supported by Bandura’s social learning theory and Kolb’s experiential learning cycle and we propose that these form the basis of the directed observer role.
One of the outstanding findings from this review is the association of observer tools with both satisfaction and equal if not better, learning outcomes in observer roles. The use of these tools may move observers from simply watching to actively observing. The activation of observers allows those in that role to experience the satisfaction and learning normally associated with hands-on experience. Simulation is described by Dieckmann et al as a social practice where people interact with each other in a goal orientated fashion [24]. The observer tool provides this necessary goal orientation for observer roles. Directed observers are focused on the learning objectives of the simulation.
This is explained by Bandura’s social learning theory, which proposes that virtually all learning acquired experientially could also be acquired on “a vicarious basis through observation of other people’s behaviour and its consequences for them” [25]. Through observation learners can build behaviours without trial and error, experience emotions by watching others and resolve fears through other’s experience. Bandura describes this as a process of attention, retention, reproduction and motivation [25]. Bethards reports on a program where “simulation experiences are designed around the observer role using the four component processes of Bandura’s observational learning construct” [26]. They postulate that this provides all their learners, regardless of role, the same opportunities to achieve the learning objectives [26].
Vicarious learning requires active listening, reflective thinking and situational engagement [27]. Nehls describes this in the context of narratives; lived experiences shared for the purpose of learning [27]. The addition of “active watching” to Nehls’ definition fits well in the simulation context. In a review of vicarious learning, Roberts concludes that vicarious learning occurs during story telling and discourse, and may require a teacher to help find meaning [28]. In the context of scenario-based simulation the story is the scenario or case; active listening and watching is engaged with the use of tools or tasks and the reflective facilitated discussion is the debriefing. It seems important that for optimal learning to occur, observers be engaged in all aspects including the debrief.
Experiential learning is viewed as fundamental to simulation and clinical practice [29, 30] and the theoretical foundations of simulation are commonly described in terms of Kolb’s experiential learning cycle [29]. Kolb proposes a cycle of concrete experiences which on reflection are distilled into abstract concepts that can then provide the basis for future actions and further testing [31]. Kolb stresses that this is an unending cycle and educators need to be aware that learners have a preference for, and may enter at different stages of the experiential learning cycle, but need to be moved through the entire process. A dangerous presumption for educators and learners alike is that concrete experience requires hands-on participation. Vicarious learning theory and Kolb’s experiential learning cycle form the theoretical basis for directed observation.
It seems that observers with the appropriate tools can benefit vicariously from the experience of the hands-on learners. Simulation is a facsimile of the clinical environment so the findings here may also translate to observation in similar clinical practice situations. This directed observer role is different to indirect workplace learning described by Le Clus, where the emphasis is on observers seeking learning to meet their personal needs [32]. However, the concept of observer learning as a social practice aligns with both [24, 32].
Stegmann reports better outcomes from observers preparing to provide feedback than those completing a checklist or in a hands-on role [15]. The impending ‘debrief’ where observers have an expectation that they will be asked to contribute their opinions about the encounter may sharpen the focus of their observations. Bandura describes this as an external motivator [25]. This ‘heightened state’ may mean observers are more likely to engage in standards of practice required for the simulation (for example, measures of good communication) and consider how the simulation participant’s performance measures up to this standard. Thidemann used reporting on standards of practice in her directed observer role guidelines [16].
The learners who did not value observer roles as highly as a hands-on role described observer roles as passive, or boring [20]. They were not fully engaged in the learning process. Emotional engagement in simulation is connected to the feeling of relevance of the scenario to the goals of the session [24]. Lack of goal direction may have prevented observer engagement. It is not clear whether there is an optimal level of activation for learning in observer roles or whether it differs between learners. Learners that valued observer roles described it as being less stressful and providing them the opportunity to see the big picture, examine details from a distance, and provide meaningful feedback to the team [11]. Stress decompression, a feature of debriefing frameworks, is necessary for reflection [30, 33].
The ability to reflect is important in the provision of feedback. An understanding of performance requirements and a judgement regarding the observed performance and its relationship to the standard is required before bridging strategies can be formulated [34]. In directed observer roles, information was provided in the form of the observer tool (e.g. checklist) defining the standards and/or objectives for the learners. The directed observers were able to use these tools to observe, reflect upon and formulate their peer feedback for the debrief.
In-scenario observers, that is non-clinical or other professional roles within the scenario, reported that lack of scripts or clear direction detracted from the act of observation because of anxiety regarding role performance requirements [20]. These aspects of role fidelity have been identified as a barrier to student satisfaction with role play [35]. The other studies that used non-clinical or other non-congruent professional roles viewed these learners as hands-on participants and did not include specific findings for these in-scenario observer roles [17, 20, 21]. Thidemann commented that the nursing roles in their scenarios were the most preferred roles [16]. The lack of clarity in the separation between professionally congruent and incongruent hand-on roles in these studies prevents drawing any real conclusions from the data. In a report of a large study for the National League of Nurses Jefferies and Rizzola Footnote 1 concluded that whilst knowledge and self-confidence were unrelated to role allocation, there was a perceived lack of collaboration in the observer role and there was a responsibility for educators to provide structure for this to occur [9].
While learners have assessed the value of observer roles, there has not been a published assessment of the value placed upon observer roles in simulation by educators or facilitators. Use of observer tools or activities and the active involvement of observers in the post-scenario debrief could be considered an indirect indication of the value educators place on learning in observer roles.
It is also unclear as to whether there is a group of learners better suited to learning through observation than learning through hands-on participation in the simulation. Whilst most of the studies used role allocation, one study [20] had a portion of study participants who either self allocated or worked through the case as a group without assigned roles. There was confusion amongst the students in this study as to which roles were considered to be observers; for example some students viewed the documentation nurse as an observer role while others viewed it as a hands-on role. No studies examined whether self-allocation to roles would result in better learning outcomes. The reasons behind self-allocation were also not examined and may be worthy of further study.
An important area for further study includes establishing educator perceived value of observational roles, and the potential impact of these perceptions on simulation education design and orientation of learners to roles within the scenarios. Activation and emotional engagement in the observer role has also not been explored, and provides future research potential.
Limitations
This review examines one small area of observational learning within scenario-based simulation. Skills training, which is often taught in groups was not included. Also excluded were non peer-reviewed reports, including a major study of more than 400 nurses [9]. This report did however inform the discussion. We also narrowly defined simulation modalities excluding virtual reality simulations where there is even more blurring of boundaries between hands-on participants and observer roles. In some studies it was unclear how the authors defined the in-scenario roles. Reporting of observer roles was in some cases a secondary finding. Lack of clarity may have biased findings. The small number of included papers also limits the conclusions.
