The results are organized in accordance with the two research questions. The first section presents significant changes in students’ understanding of teamwork and professional roles; the second section presents the conditions that were critical to enabling such transformations of understandings.
Students’ understanding of teamwork and professional roles
Three themes emerged from the analysis: (1) realizing and embracing teamwork fundamentals, (2) reconsidering professional roles, and (3) achieving increased confidence.
Realizing and embracing teamwork fundamentals
A recurrent topic was the necessity of creating and maintaining a shared view of the work process. The students expressed how the leader speaking out loud enabled them to prepare for the next step in the work process and invited all team members to suggest new ideas in a joint problem-solving process. Another way of maintaining a shared view was to ask for clarifications. As one nursing student said:
If you receive an instruction, I can say that I’m not really sure how to proceed, it is really okay to ask. (Focus group 4)
Further, the students emphasized that continuous feedback enabled the leader of the team (most often in the role of a physician) to maintain an overview, which in turn, allowed other team members to focus on their individual tasks. One nursing student said:
By giving feedback continuously, the physician gets the whole picture, while I, if I have to set up a drip, I can just focus on the drip for a while. Because then, I can let the rest of the situation go for awhile, while the physician has taken a step back and has an overview all the time. (Focus group 4)
Closely connected to the need to maintain an overview was the significance of leadership. Although the implication of keeping an open atmosphere and being reluctant to each others’ meanings, the students found that shared responsibility for the formation of leadership in the team was important and that the teamwork would be impaired and the structure of the team’s efforts ruined without clear leadership. This was considered to be especially important in acute situations, and if someone does not take on this responsibility, it is important for oneself to take the leadership.
The medical students expressed that a sense of trust in the nurses’ competence was necessary for maintaining an overview. The fact that nursing students had the necessary knowledge to carry out specific tasks and that the medical students themselves did not, enabled them to maintain overall responsibility for the situation. One medical student stated:
So if you just took it easy, then you realized that you could just stand here and look, and get the overview. (Focus group 1)
Similarly, the nursing students found that the accomplishment of discrete tasks connected to their role presumed trust in the leader.
Reconsidering professional roles
The medical and nursing students expressed that they had a poor understanding of the others’ professional roles before the simulation training. One medical student recognized a lack of basic knowledge about the nursing profession:
… it’s rather embarrassing how little knowledge we have about the others’ role. (Focus group 1)
In general, the students expressed in various ways how they got a sense of what was at stake for the other profession and how they recognized their own professional responsibilities by training together. As one nursing student stated:
This became a bit more obvious in a way when collaborating with the physicians, that we have other perspectives and that our profession has other responsibilities, so that became obvious as well. (Focus group 3)
As well as knowledge about each others’ professional roles, the students also expressed new insight into their own weaknesses and strengths in working with other professions, something that highlighted the need for continuous adaptation to each other in the team. One medical student commented:
Above all, I think I learnt really, really much about myself, about strengths and weaknesses… and above all how important it is to work with another professional group for the first time, because it is really tight and you have to adjust your work in these situations. (Focus group 4)
Another crucial experience was the importance of feeling free to cross each others’ professional boundaries and to remind each other of important measures that otherwise might be forgotten (with potentially serious consequences for real patients) and that they were allowed to do so. As one nursing student reported:
You [referring to another nursing student] suggested a drip and when we were discussing it afterwards, although it was to stepping into the doctor's territory, the doctor thought it was really positive that you came up with a suggestion. (Focus group 4)
The students expressed the importance of such transgressions in general, and the nursing students voiced the importance for the medical students to feel supported by the rest of the team in the position as a team leader.
Achieving increased confidence
Both nursing and medical students expressed that the IPSE increased their self-confidence. Performing as the leader for the team and knowing how to proceed conveyed the feeling that they could manage acute situations in real life. One medical student expressed that having the knowledge to manage the case put him in the position of being the leader, which in turn, led to a feeling of increased role confidence.
…but now I was a natural leader here, and I knew what to do, and I knew the next step. (Focus group 1)
Similarly, the nursing students found that encountering acute situations gave themselves an increased sense of confidence:
You become more secure in acute situations the more you are exposed to them, so it is really nice to have opportunities to practice. (Focus group 3)
One nursing student emphasized a development over the five scenarios during the 1-day training:
I felt strengthened when exposed to situations and experienced how I reacted to these, and I felt that I developed, just over that one day I developed a lot from the first to the last case, a kind of sense of confidence in this. (Focus group 3)
Another medical student expressed encouragement when the nursing students were pleased with his efforts:
It was really nice for me when the others told me that they felt really safe when I came in [the room]. (Focus group 2)
In parallel, nursing students, in various ways, expressed increased confidence that their competence was fundamental to successful teamwork.
Critical conditions for the transformation of the students’ understanding
Three conditions were identified as crucial for facilitating the change of the students’ understandings: (1) feeling confident in the learning environment, (2) embodying experiences, and (3) obtaining an outside perspective.
Feeling confident in the learning environment
The students experienced the atmosphere during the simulation training to be kind, permissive, and non-judgmental. That all participants were students created a sense of equality and contributed to a positive and easy going ambiance. This made it easier to speak up, have the courage to express feelings of doubts, and be more outspoken.
We were allowed to fail and kind of encouraged to make mistakes. There was this nice atmosphere, accepting, otherwise I think I would have felt blocked. (Focus group 4)
Important aspects that promoted a safe learning environment included working with a manikin, having clear learning goals given by the instructors, and encouraging the students to learn from their errors during simulation. It was also important that the team training consisted of several scenarios so that the students experienced skill improvement each time they acted in or watched a new scenario. The repeated training implied that they could foresee how the scenario would unfold. One nursing student said:
Now I feel that I understand, that I actually know what’s going on… [in critical situations]. (Focus group 3)
The participants found that learning in the simulation environment was more real than theoretical lectures. Hands-on learning was appreciated and a complement to knowledge achieved from literature. The students expressed a sense of embodying the knowledge, that this was not merely intellectual. They described real emotional strain and feelings of stress and nervousness before the scenarios started. The stress was understood as positive for enabling learning and was described as different from the stress when taking an exam. It was good to feel nervous; the level of nervousness was not experienced as any less in the simulated environment compared with real-life situations. One of the nursing students expressed:
You kind of have the situation within your body, the patient is right there in front of you, the physician arrives and wants a handover immediately, and I just have to deliver it there and then. (Focus group 4)
The sense of embodiment and presence was associated with time aspects and logistics within the team. Dealing with parallel tasks was stressful but appreciated and perceived as central to their learning. The scenarios took realistic time; every detail around the patient was performed as if in a real clinical situation. They were obliged to perform everything, take every action step by step, and communicate as a team: nothing could be hurried or pretended. Vital parameters were displayed, intravenous cannulas had to be inserted, medication had to be administered slowly, and they actually had to make the telephone call to request an ambulance. As a consequence, the students felt absorbed in the situation:
We came in to a patient who had a problem and we had to solve it. How do we do this. What do we do, who does what? It was all very concrete. (Focus group 4)
The fact that the scenarios were involving sub-acute medical conditions, taking place in various surroundings (e.g., primary care unit, geriatric ward) and team members arriving one by one as in real life contributed to experiences of being present in a clinical situation.
Obtaining an outside perspective
Self-reflection was mandatory during debriefings, and the students gave and received feedback from their peers and instructors. The debriefing was appreciated from several points of view; the students were able to gather their thoughts and structure the events that occurred during the scenarios. It was difficult to assess oneself when in the midst of action. Rather, it was easy to focus on mistakes or inaccuracies, and the students were sometimes critical of their own performance, recapitulating mistakes in their minds. To hear what their peers had observed and to receive positive feedback was very supportive in helping the students to gain an outside perspective on their own actions. In line with this, a medical student emphasized:
It was good to hear the others’ perspective on things I thought I didn’t do very well, when they saw it as very good, or other things I had done well, but they found my communication not so clear, and this gave me a feeling what they think is very important, and why it’s important that I do communicate with them. (Focus group 2)
The students expressed that it was essential to reflect on their own actions and to consider what they had done and how they worked together in the team. The students highlighted the fact that during the debriefing, they actually had to talk about what they did well in the scenarios and put words into concrete personal actions. This helped them take the knowledge and experience to a deeper level, although it was odd and unusual to be “forced” to talk about themselves. As one nursing student articulated:
The thing is that you actually articulate the take home message, you say it out loud, what to take with me … you don’t just think it. (Focus group 4)
The observers’ role was important in two ways: observing others and being observed. By observing others, for preparing to give feedback and finding examples, the significance of communication became clear. Feedback from peers was different from feedback from instructors, who the students felt might be too gentle in their criticism. Feedback from other “professions” who had seen them act was significant; the students recognized the other professions’ knowledge in a new and respectful way. Peer students could also note important aspects of knowledge or acting that they observed.