Table 5 Possible variations of Hand-it-on to emphasize certain learning goals

Include observers.

• Include an outside view on the processes during the conduct into the debriefing. What does such an outside view contribute to the analysis of the conduct of Hand-it-on?

• Prepare participants for the observer role during scenarios and debriefings. What is helpful feedback to colleagues after a simulation scenario?

Vary the objects.

• Use objects where there is something at stake for those who handle them. When handling a full glass of water there is a different “risk” for the person handling the water than when handing on a pen. Where are own risks during the care for patients? How do they impact the actions of those involved?

• Use objects that are difficult to manipulate (e.g., a thin thread). They can be used to focus on technical skills and psychomotoric challenges in combination with keeping an overview of parallel tasks. How does the requirement to concentrate on handling this object impact the overview of the situation?

Vary the direction in which the objects should be passed and/or include more tasks.

• This variation can challenge improvement plans between two rounds of Hand-it-on. How are the intentions to implement changes (work as imagined) impacted by the practicalities of the work system (work as done)?

• Discuss the impact of work procedures and personal preferences on their implementation. How do changes in procedures impact the patient care?

Separate one or more participants while giving the details of the instruction. Let the first few rounds run without them and include those participants only then.

• Discuss the integration of new colleagues into a department. How are they introduced to the tasks they are supposed to do? How are they welcomed on a social and emotional level? What influences their integration (think about time pressure, work-load, or structured introduction programs)? Are there differences in the introduction between the two departments in the variation for large groups (See Fig. 1b)?

• Discuss the importance of knowing about the history of discussions in a department. How do people understand a situation if they know only parts of its development and did not have any prior practice of the task?

• Discuss working with people who might not have been part of forming the current routines, norms, values and beliefs. How does the shared understanding of those impact the task and social level? How does it feel to accept the features of the work system if you were not a part in forming them?

Include “hidden” instructions for briefed role players. You could ask them to frequently “drop” objects or to not concentrate on the process, causing delays. Remember to reveal the hidden instructions during the debriefing to protect your role player. They would not like to come across as “obstructive” or “unable” in reality.

• Discuss how the group reacted to such a “low” performer. How can a work team or an organization deal with a worker who does not perform to standards? How would a team identify such a person in the first place? What would impact the reaction to such a worker? Is there a difference in how you treat people who you like vs. those you do not get along with? How does it feel to observe this person? How does it feel to be this person? What do patients think about the low performer?

Include “stressors” such as loud music, noise, or the threat of moving the organization to a different country.

• Discuss the impact of such disturbances and ask participants to draw connections to real life. How do different operation room settings with their lighting, temperature or noise conditions impact performance?

• Explore the differences in the experience and in handling of such stressors between the individuals involved. Who is disturbed by such external factors, who can deal with them easily? What are the coping strategies?