An activity theory perspective of how scenario-based simulations support learning: a descriptive analysis

The need to examine differences in scenario-based simulation contexts

The dominant frameworks for describing how simulations support learning emphasize increasing access to structured practice (i.e., repeated or deliberate practice) and the provision of feedback [1, 2]. However, our understanding of how simulations support learning (e.g., structured practice, feedback) may be influenced by learning strategies employed in skills-based simulations which prioritize focused practice of a singular skill, while scenario-based simulations present student participants with a holistic problem or situation to analyze. For example, in Issenberg and colleagues’ Best Evidence Medical Education (BEME) Review, of the 109 included studies, 90 (83%) examined skills-based contexts [1]. Additionally, McGaghie and colleagues’ meta-analysis compared simulation-based medical education (SBME) using deliberate practice (DP) with learning in the clinical setting; of 14 included studies, 12 (86%) addressed learning in skills-based simulation contexts versus scenarios [2].

However, although both skills- and scenario-based simulations are commonly employed, scenario-based simulations (ScBS) may have unique properties in design and implementation that set them apart which, in turn, may influence learning processes. For example, skills-based simulations primarily emphasize the focused teaching and practice of a specific procedural skill [3, 4]. By comparison, ScBS are often employed when the desired learning outcomes include working in a team-based context, practicing communication skills, or responding to a crisis or critical patient event [5]. Additionally, whereas skills-based simulations often seek to minimize complexity, ScBS are employed to incorporate the complexities associated with clinical practice, including engaging socially with the patient or support persons (e.g., simulator, standardized patient) and interacting with other healthcare professionals [5–7].

ScBS are also described as possessing characteristics associated with sociocultural and situated learning practices. For example, in a ScBS, a narrative is employed to guide student participants’ engagement in which learning activities are designed around a story or a problem that needs to be explored or resolved [6]. Furthermore, in a ScBS, student participants are assigned to designated clinical roles, such as that of the nurse, physician, or other healthcare professionals, and are expected to conform to the behavior- and practice-oriented conventions of their assigned roles [5, 8, 9]. However, despite these differences in use, design, and implementation, simulation-based learning (SBL) research rarely disaggregates differences between skills-based and scenario-based simulations.

The need to examine how participation during ScBS supports learning

To date, empirical studies in health professions simulation have frequently focused on determining if SBL supports improvements in participant satisfaction, diverse learning outcomes, and in some cases, outcomes in the clinical setting. For example, several meta-analyses suggest that SBL supports improvements in medical knowledge, psychomotor and communication skills, time to complete a skill, and self-efficacy [2, 10, 11].

In addition, learning associated with scenario-based simulations often prioritizes reflection and debriefing to support learning [1, 2, 12, 13]. For example, according to Rudolph and colleagues, reflection helps individuals make sense of their experiences and scrutinize their assumptions and beliefs [14]. Palaganas and associates suggest that student participants can also engage in sense-making efforts through discussion with faculty and peers when they pause to reflect during a scenario [13]. Furthermore, according to Fanning and Gaba, participation in a simulated encounter is often considered a normalizing event in which student participants engage in a shared experience (e.g., code team response) that, in turn, enables reflection processes [12]. Although reflection is critical to learning, these perspectives primarily emphasize the role that verbal discourse can play in learning processes, yet studies examining how student participants may learn through participation in a ScBS are limited. Furthermore, framing learning as an activity that occurs after a simulation reflects traditional cognitive perspectives of learning.

By contrast, some studies examining student participants’ experiences in simulation suggest they may learn during scenario participation. For example, Kneebone and colleagues assigned student participants to one of two procedural scenarios: insertion of a urinary catheter or wound closure using a hybrid simulation strategy [3]. Student participants reported that in addition to learning the designated skill, they also became aware of the importance of maintaining patient privacy, learning where to find supplies and materials, and interacting with the standardized patient [3].

In another study, Mikkelsen and colleagues assigned student participants to either case study sessions or a ScBS to learn how to manage cross infections [15]. Student participants who engaged in the ScBS reported that as they partook in the scenario, they became aware of the complexities of patient care through the consequences of their actions. For example, if a student participant did not acquire the proper equipment or supplies before entering the room of a patient on isolation precautions, they then had to exit, collect the needed supplies, and start again [15]. As a result of participation, student participants not only learned how to care for a patient on isolation precautions, but also learned the importance of pre-planning their care.

Furthermore, Lasater [16] examined student participants’ experiences of learning clinical judgment using ScBSs. The findings suggested that student participants learned during the ScBS when the simulator physiologically responded to their actions, thus allowing them to understand the consequences of their actions (e.g., cardiopulmonary depressions following administration of a narcotic agent) [16].

Importantly, the findings from Lasater, Mikkelsen et al., and Kneebone et al. suggest that student participants learned through the process of participation in a ScBS [3, 15, 16]. Although these studies importantly focused on student participants’ self-reported experiences, there have been no studies focusing on which activities could promote learning within a ScBS. One of the first steps is to undertake a comprehensive examination of participant activity to understand how ScBSs may support learning.

The current study

Theoretical framework: activity theory

To support this study’s goal of in-depth analysis of participant activity, this study was informed by Engeström’s first-, second-, and third-generation perspectives on activity theory (AT). AT is often used by researchers as a descriptive tool to map the interactions between individuals and their environment [17, 18]. Systematically mapping activity can help researchers examine meaning-making processes as embedded in dynamic emergent systems [17, 19].

According to Engeström, first-generation AT emphasizes Vygotsky’s mediated action triangle that highlights how individuals use artifacts or tools to achieve their goals [17]. Engeström’s second-generation AT, often referred to as activity systems analysis, advances first-generation perspectives because it helps elucidate the collective nature of human activity by accounting for the roles individuals play and the rules that may guide them [17]. This added emphasis on roles and rules is intended to highlight the complex interactions within an activity system [17, 19]. Third-generation AT supports analysis of multiple points of view to highlight interactions between activity systems [18, 19]. The use of third-generation AT requires the analysis of at least two activity systems, though multiple activity systems may be available for examination [18].

Central to all three generations of AT is the inseparability of learning and doing. According to AT, learning is conceptualized as practice [18]. This contrasts with traditional learning theories that position learning as occurring prior to or after an individual’s performance in an activity. Importantly, when discussing activity, activity theorists are not just concerned with what individuals do, but are also interested in doing as a transformative process [17, 20]. For example, nursing students participating in a ScBS often must assess a patient’s vital signs. In assessing vital signs, students may perform specific activities, such as palpating a pulse or using a blood pressure device. The practice of assessing vital signs is governed by specific rules, such as how and where to place the blood pressure cuff or where to locate the pulse. In performing these activities, nursing students gain new knowledge about the patient that they must then integrate into their care plans. They must consider the information gained, decide what it may mean (e.g., hemodynamically stable or unstable), and, in turn, determine what they should do next.

Yamagata-Lynch defines activities as “mediational processes in which individuals and groups of individuals participate, driven by their goals and motives, which may lead them to use new artifacts or cultural tools” (p. 17) [17]. Participants can include an individual or a group of people engaged in an activity [21]. Their goals or objectives are the physical or mental product(s) they seek during participation (e.g., postpartum assessment) [21]. Tools include culturally specific artifacts that participants use to achieve their goals [21]. For example, when a participant assesses a patient’s vital signs, they may use a manual or automated blood pressure device to achieve this goal. Rules are the guidelines, conventions, or protocols that govern participants’ activity in the system, either explicitly or implicitly, such as patient care guidelines or commonly accepted assessment processes [21]. Roles are the division of labor among actors in the system [21]. Figure 1 provides a generic AT diagram which is often used to heuristically represent AT concepts.

Design

An exploratory descriptive analysis was selected using multiple qualitative methods, namely, narrative, video, and activity system analysis, to support the goal of rich description of the types of activities student participants engaged in that may support learning. The strategy of using multiple qualitative methods was selected to help better account for the complex and dynamic activity usually present in a ScBS.

Video sample

A purposive sample of four video-recorded scenario-based simulations representing commonly cited motivations for employing them (e.g., team training, communication skills) was sought [22]. Additional sampling criteria included (a) ScBS that were designed to represent the complexity and the social practices of caring for patients and (b) inclusion of student participants who regularly engaged in ScBSs, which was reasoned would afford analysis of student participants’ typical activity, rather than the activity of student participants becoming familiar with engaging in a ScBS.

Following institutional review board (IRB) approval, 34 previously video-recorded scenarios were identified. Because the identified video recordings were captured during the National Council of State Boards of Nursing (NCSBN) National Simulation Study, approval from the NCSBN was also sought. The identified videos had been recorded during the third semester of an accelerated second-degree baccalaureate program during a Nursing the Childbearing Family course. All student participants portrayed in the videos had participated in ScBS activities at least every other week, so they had the requisite experience that was sought.

Analysis

Data analysis was conducted in multiple stages. Stage one focused on identifying the types of activities in which student participants engaged in and verifying their frequency and regularity across all four videos. Stage two focused on re-aggregating the activity system to support analysis of the interactions between student participants and the ScBS context, which included the physical environment, standardized patients, and other simulated participants, for example [17].

Stage one

Drawing on Ollerenshaw and Creswell’s descriptive restorying methods [24], a narrative describing each participant’s activities was composed [25]. First- and second-generation activity theories were used to help focus restorying (e.g., recording what tools nursing students used, who they communicated with, verbalized goals). Additionally, except for ahs, uhms, and pauses, each video was transcribed verbatim, including the social utterances of all participants (e.g., student participants, standardized patients, and other simulated participants). Lastly, each narrative and transcription was re-reviewed for accuracy. This first stage served to disaggregate the rich and dense activities of the scenario.

Following restorying, open coding procedures were used to categorize student participants’ activities. This entailed reading and coding each restoryed narrative and transcript to identify the tools, roles, and goals of each participant [26, 27]. The instructional design documents for each scenario were also read to search for additional tools, roles, and scenario goals.

Initial codes were then compared across the four videos using video analysis software (Studiocode) to determine their regularity and frequency. Accounting for regularity and frequency helped verify initial codes and identify new codes that were not revealed during earlier coding efforts. Following this step, initial codes were consolidated into three major categories by grouping similar initial codes together.

Stage two

During the second stage of analysis, which supported the goal of analyzing how student participants engaged, a second cycle of coding was conducted [26]. This involved drawing on second- and third-generation AT using the categories of activities generated in phase one to create subject-tool-object activity system diagrams (see Figs. 1 and 2) for each student participant. This step served to make explicit what tools and artifacts mediated student participants’ goals to help describe how they engaged during the scenario. The use of third-generation AT supported analysis of scenarios in which multiple student participants were engaged (e.g., uncomplicated postpartum assessment) to support analysis of their interactions and multiple perspectives.

Following each stage of analysis, the findings were presented to an interpretive community for feedback and guidance. The interpretive community was comprised of two individuals with expertise in SBL in nursing education and two educational psychologists with expertise in studying complex learning environments. The community provided guidance related to categorizing participant activity and made recommendations about data analysis efforts.

Activities student participants engaged in during scenario-based simulations

How student participants engaged in scenario-based simulations

Each of these themes is discussed below.

Influences of assigned role

The analysis suggests this difference in activity may have occurred because student participants assigned the role of primary nurse were expected to complete more complex goals, such as conducting a complete uncomplicated postpartum assessment or recognizing that the laboring patient in the post-epidural hypotension scenario needed escalation of care. This added complexity is also reflected in the frequency counts, where in all four scenarios, primary nurses engaged in more activity overall (see Table 4). Additionally, in both the post-epidural hypotension and postpartum hemorrhage scenario, support nurses arrived later, and when they arrived, they were often assigned specific structured interventions, such as administering fluid or fundal massage, by the primary nurse. Table 5 provides a summary of the types of clinically relevant activities student participants engaged in in all four scenarios based upon their designated clinical role.

Sequencing and integrating activities to make sense of the clinical presentation

In this example, the primary nurse sequenced her activities by first educating the patient about her assessment plans, performing the planned structured intervention of auscultating the abdomen, followed by palpating for the height of the fundus. Additionally, together with her physical exam findings, the primary nurse further made sense of the patient’s clinical presentation by engaging in dialog with the patient by asking additional diagnostic questions. This example highlights how the use of physical tools and artifacts and social interactions are critical to the sense-making process. Additionally, she made her understanding of the findings explicit when she verbalized her documentation plans and when she educated and counseled the patient about her findings. Student participants in all four scenarios demonstrated similar patterns of activity.

In this example, the participant portraying the primary nurse struggled to provide a cohesive accounting of the patient’s situation to the support nurse. This interaction, in turn, led the support nurse to quickly assess the situation herself by conversing with the patient and evaluating the patient’s vital signs (clinical artifact). Although this exchange highlights how a student participant can struggle to engage in ideal sequencing of activities, the student participants in this vignette still made the effort to thoughtfully sequence their care.

Coordination and distribution of activity

Student participants achieved their goals by making sense of the clinical presentations by coordinating their efforts with their peers assigned supportive clinical roles, the standardized patient and simulated participants portraying other roles (e.g., charge nurse). Coordination of activity with others was present in all four scenarios and included efforts to perform structured interventions and meet the faculty-intended goals of the scenarios. For instance, the previous example in Table 7 demonstrates how the support nurse’s interactions buttressed and guided the primary nurse’s activity. Additionally, in the fetal demise scenario, although the participant engaged in the scenario without the co-presence of another nursing student or healthcare professional, she coordinated her activity with the patient and her support person. This highlights the critical role that all participants in a ScBS (e.g., student participants, standardized patient(s), and simulated participants) can play.

In addition to coordinating efforts, student participants also distributed the workload of care across multiple team members. For example, in the uncomplicated postpartum scenario, the primary nurse and secondary nurse coordinated their activities to complete the goal of an uncomplicated postpartum assessment (see Table 5). Together, they achieved the appropriate provision of care. Figure 2 highlights how three student participants collaborated and distributed care to support a patient experiencing a postpartum hemorrhage.

The activity diagrams in Fig. 2 highlight how student participants distributed the workload across three nursing students to obtain the shared goal of stopping the postpartum hemorrhage in a hemodynamically unstable patient. Although all student participants worked towards the same goal, each undertook a specific goal (e.g., catheterizing the patient, administering fluids).

Implications for instructional design features of scenario-based simulations

These findings are consistent with prior research emphasizing the role that simulations play in affording student participants access to practice diverse, clinically related skills [2, 10]. The findings are also consistent with prior guidance indicating that scenarios support learning to interact with conscious patients and other team members [3, 5]. Importantly, by focusing on participant activity, these findings make explicit some of the major categories of activities student participants may gain access to during ScBS participation, specifically the use of physical tools and artifacts, diverse social interactions, and structured interventions.

The findings from the activity analysis indicate that student participants did not partake in focused repeated practice of a specific clinically relevant activity during a single scenario. However, when considering student participants’ activity across all four scenarios (see Table 5), the data showed that opportunities to repeat practice of some activities were distributed across multiple scenarios (e.g., postpartum or intrapartum assessment, interpretation of vital signs). Thus, these findings extend Issenberg et al.’s and McGaghie et al.’s reviews by shedding light on how educators could operationalize repeated practice opportunities when employing ScBS in their curricula [1, 2].

The frequency and regularity analyses may offer new insights into ways to consider scaffolding student participants’ experiences by thoughtfully considering the complexity of each role portrayed in the scenario. For example, the analysis suggests that student participants assigned to roles with greater levels of responsibility (i.e., primary nurse) conducted more complex care, relied on more subjective artifacts (e.g., palpation of the fundus), and were required to determine when and what support persons were assigned to do. Thus, simulation stakeholders could consider assigning student participants with greater amounts of training or ability to more complex roles. Conversely, less experienced student participants could be considered for support roles that may entail less complexity. This may enable learners of diverse abilities to simultaneously partake in a ScBS.

Considering this scaffolding approach is consistent with Lave and Wenger’s theories regarding legitimate peripheral participation (LPP). LPP indicates that newcomers, such as novice student participants in a scenario, can gain greater experience in a community of practice when they have access to opportunities to engage in simple or lower risk tasks that are nonetheless important to the community’s goals [28]. Furthermore, per Lave and Wenger, participants benefit from both direct participation in a meaningful activity, while also benefiting from modeling provided by their more capable peers [28]. Additionally, scaffolding using such an approach is consistent with recent best practice guidance issued by the NCSBN, which indicate that simulation objectives should be aligned with student participants’ developmental level [29].

Furthermore, the findings are also consistent with prior guidance associated with selecting scenarios to give student participants opportunities to practice diverse communication skills [5], breaking bad news, [30] or supporting clinical situations related to death and dying [31]. Importantly, the activity systems analysis highlights how ScBS affords student participants access to selecting and sequencing social interactions with clinically relevant activities (see, for example, Tables 6 and 7). These findings may provide insight into how partaking in ScBS might support learning clinical reasoning or engage in diagnostic decision-making.

Implications for learning in scenario-based simulations

The findings are also similar to results from Kneebone et al., Lasater, and Mikkelsen et al., who reported that student participants experienced learning during ScBS as occurring through engagement in ScBSs [3, 15, 16]. The descriptive use of AT revealed how student participants transformed objects and how other system components, such as social interactions with peers and standardized patients or accessing and interpreting diagnostic findings, mediated this transformation. Although previous literature has emphasized reflection and debriefing as the primary ways to engage in sense-making associated with ScBS [12–14], the findings of this study suggest that sense-making may take place during ScBS participation as well.

By undertaking an in-depth analysis of participant activity, the findings also highlight the complex and emergent properties of these ScBS activity systems. This was exemplified in the activity analysis in which the components (e.g., subject, tools, objects) of the ScBS activity system were not isolated from each other but were dynamic and continuously interacting with each other (see Tables 6 and 7, Fig. 2 for example) [17, 18, 32].

The activity analysis also highlights the nested activities within the ScBS activity system [32]. Barab and colleagues define nested activities as those activities or actions that could be conceived of as separate activity systems. For example, although the faculty-selected goals of these scenarios were explicit, the students often voiced their own goals during the scenario (see, Fig. 2, for example). This nestedness was especially highlighted in the team-based scenario in which each participant’s activities differed, such as one participant’s practice of external uterine massage while another participant prepared medication, yet they all worked towards the common goal of resolving the postpartum hemorrhage. These complex, emergent, and nested properties could have significant implications for formative and summative assessment of student participants.

Lastly, the findings potentially extend our understanding of how scenarios may support learning team-work behaviors when they afford student participants opportunities to coordinate care and distribute the workload with peers and other healthcare professionals, while simultaneously interacting with the material environment (e.g., stethoscope, thermometer, diagnostic findings). These characteristics are consistent with Hutchins’ [33] concept of distributed cognition which suggests that interaction is “deeply multimodal and composed of a complex network of relationships” (p. 376) [33]. Multimodality refers to the different embodied mediums or tools (e.g., physical tools, social interactions) that individuals use to achieve their goals [33]. This complexity and multimodality is reflected in Tables 4, 5, 6, and 7 and in Fig. 2, which highlight the frequency and diversity of activities in which student participants engaged. Thus, ScBS could alternatively be framed as simulated clinical systems in which the unit of analysis would include examination of how student participants coordinate while integrating the use of culturally relevant artifacts to achieve a goal. Viewing scenarios as simulated clinical systems potentially provides simulation stakeholders with alternative ways to examine how student participants collectively achieve goals that go beyond solely relying on verbal reflection or outcomes assessment of performance [34].

Limitations

Although this study provides an in-depth examination of the types of activities student participants engaged in during high-quality ScBS participation, the strategy of rich description required the use of a limited number of video-recorded scenarios. Additionally, these videos depicted senior nursing student participants who could function independently with limited or no support from faculty, thus the analysis may only reveal the types of activities in which more experienced student participants engage. Future research should include analysis of diverse levels of learners (e.g., novice, intermediate) and diverse types of learners (e.g., physicians, respiratory therapists) who partake in SBL activities. Furthermore, the choice to use diverse types of scenarios did not allow for analysis of how consistent the patterns of activity were for a single scenario type (e.g., communication). Future research should take consistency into consideration. Lastly, although this analysis provides a framework that can be used to describe how observing student participants’ activities may support learning, this analysis did not include participants’ reflections on their activity. Future efforts could include the use of stimulated video-recall, which could be used to triangulate student participants’ intended goals.