By Kimberly Schertzer (@KASchertzer) and Sarah R. Williams (@SRWilliamsMD)
It’s happened to all of us.
We’ve run a great simulation session, the participants were engaged, the scenario progressed as planned, and the debriefing was flowing along nicely.
Then suddenly, you feel it… a chill in the air.
It’s not clear what happened. Where body language was previously open and conversation was flowing, you now encounter crossed arms, terse answers, and the shutdown looks of participants… who no longer appear engaged.
These teaching situations are difficult to salvage, and when they occur early in a simulation session, they can ruin the learning environment for the remainder of the day. What happened? And can it be fixed?
Malcolm Knowles may have your solution.
A Brief Overview of Andragogy
In Andragogy Learning Theory, Knowles describes adult learners as different from children in four basic ways, which he refers to as his “crucial assumptions.”1
Adults have a:
- developing sense of self
- wealth of experiences
- change in their motivation to learn
- focus on problem solving
Each of these critical assumptions about adult learners carry implications for clinician educators. But Knowles’ first assumption, the notion of self-concept, frequently spills into the simulation lab with dire consequences.
(1) Self-concept is one’s sense of self, developed over time. Children are born fully dependent on others, and they identify themselves in relation to others. That is, they identify as someone’s child or sibling. As they grow older, they become more self-sufficient and identify themselves by the unique social roles that they hold.1 They identify as a Lakers Fan… or a guitarist… or a surgery resident… Simulations that reduce trainees to previously held or inauthentic identities will fail to hold the attention of your learners.
(2) Experiences and knowledge shape self-concept. Adults resist learning — and sometimes even actively rebel — when the environment is inconsistent with their self-concept as fully competent, independent adults. This also explains why learners behave in ways that, on the surface, might be unexpected. Otherwise pleasant and easy-to-teach trainees may turn dour during simulations that fail to teach to their self-assessed levels of expertise.
(3) Motivations to learn change over the lifespan. Emotional scars from feeling disrespected in a classroom may prevent some adults from wanting to engage in lifelong learning. Knowles describes the longstanding effects of traumas in childhood learning environments. Yet, adults may be willing to participate if they find a “reward” – like a grade in medical school — that outweighs any unpleasant feelings. Be aware that some trainees might prefer not to learn in a simulation lab, doing so only for the course requirements.
(4) Adults seek new knowledge to solve practical, relevant problems. Medical trainees learn because they want to care for patients and one might think they would value the opportunity to practice with simulated patients. However, many students have experienced previous simulations that were perceived as evaluative, malignant, or belittling. Those past traumas make your simulation sessions difficult to teach. Look for students who are defensive during debriefings or who try to find “tricks” in the cases that may allow them to avoid errors and the accompanying negative emotions.
Winning Over the Disgruntled Learner
- Andragogy suggests: Learners may have memories of suboptimal or negative simulation experiences and may be defensive in future simulations as a result.
- Overcome this: Be more explicit in setting the stage for a psychologically safe learning environment through a thoughtful “Prebriefing.” Explicitly describe the rationale for the simulation, describe your own experiences as a learner, and normalize the anxiety that comes from prior, negative experiences.
Knowles goes on to describe that even when adult learners do agree to re-engage in education, they may self-sabotage. They may behave in a way that makes the instructor treat them exactly the way they anticipated being treated, similar to how they were treated as children. These behaviors may include sitting in the back of the room, not making eye contact, or not engaging when the instructor calls on them. Knowles describes “shock and disorientation” when adults experience positive learning environments instead of those they preconceived.1
- Andragogy suggests: Learners who self-sabotage may be revisiting school age trauma and difficult classroom memories at this later stage of training. Their behaviors often recreate learning environments with similar challenges and defining features. This fuels a self-fulfilling prophecy of negativity that began long before they entered your simulation center.
- Overcome this: Watch for self-sabotaging behaviors, and when recognized, work diligently to manage your reactions, emotions, and teaching style. Do not fall prey to the expectations of your trainees based on their experiences with other instructors.
When a debriefing session suddenly sours, remember Knowles’ Andragogy Learning Theory and consider the impact of self-concept for your learners. Did a previously bad simulation session result in such negative emotions as to threaten their sense of self and agency as an adult learner? Maybe. Adjust your teaching, redirect the session, and create a safe and positive space for your learners to rediscover simulation.
In the second of our two-part post, we will unpack the relationships between simulation, self-concept, and identity threat.
Come back for Part 2 on Tuesday, July 20th!
1. Knowles, M. (1970). The Modern Practice of Adult Education; From Pedagogy to Andragogy. P 53-70. London, UK. Association Press.
2. Pasquale, S.J. (2013). Education and Learning Theory. In Levine et al (Eds.). The Comprehensive Textbook of Healthcare Simulation (51-55). New York. Springer.
About the Authors:
Kimberly Schertzer, MD is associate professor of emergency medicine and Director of Medical Simulation in the Department of Emergency Medicine at Stanford School of Medicine.
Sarah Williams, MD, MHPE is professor of emergency medicine and former residency program director in the Department of Emergency Medicine at Stanford School of Medicine.
Edited by: Michael A. Gisondi (@MikeGisondi),
Photo Credit: Pixabay
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