Simulation-based Medical Education: A Transformative Bridge of Complexity

Author: Mark Neill

Neill, Mark, 2016 Simulation-based Medical Education: A Transformative Bridge of Complexity, Flinders University, School of Medicine

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Learning by simulation-based education has become a dominant medical teaching method (Bleakley, Bligh et al., 2011) and now represents a globally established central thread in the fabric of medical education (McGaghie et al., 2010). This thesis aims to cultivate knowledge and understanding of simulation-based medical education (SBME) viewed through a new exploratory lens. This lens represents the conceptual framework (or tentative model) proposed by this thesis that the SBME setting, as an experiential learning proxy, can provide learners with an educational context or place which can trigger and support transformative development of their professional identity as a doctor. This exploratory view forms an aspect of the broader canvas of SBME experiences which emerge as learners are immersed in an increasing clinical learning environment, with growing roles and graded levels of responsibility.

This thesis’ tentative model is informed by Mezirow’s (1991) Transformative learning theory and the theoretical constructs of professional identity and aspects of identity and its formation. This exploratory lens is focussed upon graduate-entry medical students and doctors as they journey along their temporal participation in simulation-learning activities. Temporal depicts first year medical students’ often initial introduction to the doctor’s role through simulated patients, which progresses to more immersed and complex demanding high-fidelity medical situations such as clinical emergences, in which later-stage students and doctors participate. This thesis’ look at another aspect of learners’ SBME experiences stands to capture new insights and understandings, which may further contribute to the central role simulation-learning plays in contemporary medical education in collaboration with its primary aim of preparation for and transfer to clinical practice.

The mixed methods cross-sectional design of this thesis represents a pragmatic and flexible approach to test its tentative model and manage this study’s six participant cohorts comprising medical students and doctors, the four study settings, four data gathering methods and the associated quantitative and qualitative analytical methods. This research approach provides a rich and diverse volume of findings which lead to this thesis’ Simulation Identity-formation Model (SIM) as a theoretical account of an aspect of participants’ SBME experiences. This model encapsulates the temporal and transformative nature of professional identity development which can be facilitated by participants’ simulation-learning experiences. Three key findings are embedded in the SIM: 1) Situated and progressive identity formation, 2) Tolerance of ambiguity and reduced uncertainty, and 3) SBME - a transformative bridge of complexity.

The first key finding depicts medical simulation-learning as a situated and progressive educational context where learners can encounter legitimate opportunities to develop knowledge and skills to inform their evolving professional identities. This situated focus is informed by the sociocultural learning perspective of legitimate peripheral participation (Lave & Wenger, 1991) which exhibits learners’ progression and participation in their simulation activities as a centripetal movement towards fuller participation in the medical profession. The SIM depicts this centripetal movement to involve transition between the various identity-positions that participants occupy along their identity formation journeys, from which they depart and transition towards another position of a more participatory and contributory member as a doctor. The temporary nature of these identity-positions capture the ongoing refining nature of professional identity development, and suggest the role SBME can play to promote and facilitate such development of a place within the medical profession.

The second key finding uncovers the tolerance to ambiguity and reduction in uncertainty which can be associated with medical students’ and doctors’ transition between professional identity-positions. SBME is illustrated as an educational setting where learners can be prompted to develop mechanisms to manage both ambiguity and uncertainty, where ambiguity is progressively recognised and accepted as a pervasive element inherent in the complexity of the doctor’s role. This is shown to facilitate learners’ reduction in uncertainty about viewing themselves to occupy the doctor’s role. This key finding therefore exhibits synchronous development of tolerance to ambiguity and reduction in uncertainty as participants journey towards their individual goals of being the type of doctor they wish to be in the clinical environment.

The third key finding represents the core theme of this thesis and encapsulates SBME as a transformative bridge of complexity to the clinical setting, along which learners can be prompted and supported to interactively and relationally develop their professional identity as a doctor. Such identity development is informed by complexity theory and depicted as a complex adaptive system, where emphasis is placed on the non-linear relational and multidimensional elements which constitute the doctor’s role. These elements are shown to be temporally encountered throughout participants’ SBME experiences which are illustrated to be negotiated and self-organised along participants’ ongoing identity formation journeys to better envisage themselves as being a doctor.

This thesis’ Simulation Identity-formation Model (SIM) presents another way SBME can be thought of as learners’ preparation for and transfer of their skills to clinical practice. A new domain of understanding is therefore opened-up which can contribute further to the expanding empirically-based theoretical knowledge of the central role SBME plays in contemporary medical education. The SIM offers different insight into how and why SBME can facilitate students’ transition towards ‘becoming’ a doctor, and clinical doctors refining themselves ‘being’ a doctor i.e. shaping their evolving individual professional identity as a doctor. This thesis’ SIM also contributes to contemporary recognition of the relationship between clinical and simulation-based practice as a mutually dependent two-way process.

Keywords: Simulation-education, Transformative learning, Professional Identity

Subject: Health Education thesis, Medicine thesis

Thesis type: Doctor of Philosophy
Completed: 2016
School: School of Medicine
Supervisor: Prof Jennene Greenhill