Questões de uma vontade individual sem contextos

The whole course has an activity that encourages reflection. Reflection is trainedin the daily routinesofthe hospital practicum, of the participation in thesimulation, of the seminar activ-ity ofstudent presentation and generalreflection. ‘Reflective seminar’ is also used as a term for the simulationsession, communicating that the technologicalcontext is subordinated to the mental and cognitive dimensions of reflecting upon practice. Inviting students to the u ni-versity for a simulation provides stimulithatinduce many opportunities forlearning. The

simulation creates situations that highlights certainpractices andinvitesstudents to reflect on themwith more experienced practitioners (teacher/facilitator/operator). In this context teachers – and sometimes students – refer to research evidence for arguments. The teachers said that previously one rarely heard a trainednurse utter that ‘new research’would improve anything. Now, however: ‘we educate nurses who have a much lower threshold for standing up and actually claim they know something because they’ve read an article about it, and that’s what was done, and possibly we could learn something from it.’ (Interview, teacher). Gradually, they find that usingreflective contexts for discussing practice and theory as two equally important dimensions is what simulation is good for.

The simulation is based on a prescribed casethat is enacted assuch. In the case itself, stu-dents aim atfilling a role they sense asprescribed as faras the responses from the manikin go. Theyknow of the duality of the situation, that it is possible to make mistakes in the nursing actions, and that the mistakes will not be interpreted asdetrimental or ruining the student habitus, and yet, fellowstudents and supervisorsare observing and noting their actions in an evaluative manner. The nursing situation in the simulation is not the time andplace to alter routines and outline newways of nursing patients with‘cardiac arrest’. The anecdotes and rumourscirculating among students about ‘patients’ dying afterstudent malpractice inthe nursing simulationare vibrant and alive. Similarly, teachers refer to those occasions when that actually happened because it underlines the seriousness of the professional acts, and re-minds the students of thecosts of coming unprepared to the simulation.Indeed, sometimes patients are impossible to save from death, and this ultimate result is also considered w orth-while to add to the students’ registry of situations that need to be mastered. However, g ener-ally, the facilitator and operator will seek to avoid those situations (Interview, teacher).

Even ifstudents tend to navigate familiarlandscapes during thesimulation, they are ex-posing themselves to risks and challenges to their comfort zones. The teachersconstantly ne-gotiatewhere those boundaries go for the individualstudents, and are predominantly sup-porting a view of building the simulation competenciesgradually and withcare. Theyare un-willing togamblewiththe resilience and robustness ofthestudent. Knowing that task diffi-culty level is found to be animportant variable whenit comes to the efficacy of learning, and that clinical failure(suchas the simulatedpatient dying) is likely to undermine the confidence of students theyare watching out for the area of the ‘possible learning zone’.

Observing and reflecting on the practicalsimulations takes place in two different contexts.

The firstpart is divided between the two nursestaking care of thepatient, while the rest are spectatorswatching the streamed pictures on the screen. While the acting nurses arevery busy, the spectators during the observation of the screening are rather silent. Comments are utteredas the procedure runs, and this is imaginative and interpreting talk about what takes place, with whispering voices, through sighs and grunts. In varying degrees they see them-selves as the acting nurses, and identifywith the critical situation the acting nurses are in. Second, sittingin and going through the formal debrief is the next option for exploration and active knowledge construction. While the debriefing is both a matter of finding the ‘correct answer’ and ‘reflecting on alternatives’ the desire to find the bestanswer or reflection is sig-nificantlymorepresent in the mood and tone of the situation.Still, the ‘as if’ context is upheld and the facilitator and operatorsmaintain a positive and encouraging sentiment for seeking

knowledge in an open-ended manner. One obvious challenge is to make the learning oppor-tunities forspectators and acting nurses equally intense and daring. While the spectators know their turn willcome, sooner or later, the pulse and excitement of the acting nursesis more likely to behigher. On the other hand, some students might learn more from being an observer, than being ‘on stage’.

We noticed that the debriefing situation was given a relatively narrow time slot (15 minutes).Knowing that research suggests the debriefing tobethe most valuable situation for learning, spending little time on the dilemmas and critical moments that occurred can be jus-tified by the fact that it is anaturalconsequence of a busy everyday practice. It wouldnot be natural to spend significantly moretime than allowed by a working context. Spending more time,however, wouldallowusing a playback of the streamed sequence, winding back and forth, and do more thorough analytical techniques for finding issues and actions that might be debated.

Reflection ongeneralmatters about thepracticumtakesplacein two contexts –with the supervisor on site in hospital, andin the generalseminar. Ourobservation covered the gen-eral reflection, which was an open-ended Q&A session. The interview withstudents in practi-cum and theinterview with the supervisor revealed that practicum is often ratherbusy, af-fording fewpauses for thorough probing difficult or sensitiveissues. In thepracticum, stu-dents sense that thepace of notetaking, planningnursing activities, writingsummaries and reflections is too extensive. The context of the reflectiveseminar gave more space for bringing inafterthoughts, criticalquestions and rethinking than the daily practiceinthe hospital al-lowed.

The feedback in the simulationisgiven orally during the debriefing. One might also char-acterise the supporting corrections the facilitator gave during the simulation as a sort of ‘in-the-moment-feedback’. In the debrief the students receive more oralfeedback both onthe actions taken and on the utteredreflections.Thesizeof the group makes iteasy for the facil-itator to get a good impression ofhow the group members behave. The simulationsituation is also an assessment context. The demarcations of what is up for assessment and not are difficult to track. The students express that observing other students’ presentations is valua-ble and sets standards for finding interesting topics and do research in the literature for rele-vant information that might illuminate the topic chosen. Most students say they value the pedagogicalpresentations verymuch.Theyhighlight the investigation they get to do about a topic of relevance and interest. The activity gives them experience with presenting and ar gu-ing professionally.

Most of the students are satisfied with the reasons for the requireddaily plan for aims and reflection during practicum. Despite this, some students are dissatisfied with the feedback they are givenon their written reflections. They wish for more detailed and constructive feed-back and to get better assessment of their achievements. Sometimes they felt that they wrote too much and nobody wasactually reading it. Feedback like ‘Good’ does not say much about their performances. Usually they manage to establish reasonable aims for the dayin cooper-ation with their supervisor.

The simulation is considered a highly refinedtechnologicalenvironment. The devicesand technologiesoperating to make the simulation realistic are ‘hidden’ and need to be so. In

terms of media theory, the manikin and its characteristics tries to emulate reality and disguise its technology (Bolter & Grusin,1999). The radio communication between operator and is a visiblenot-like-real device, and similarly,thestreaming device that broadcasts the simulation to the reflection room is extra to otherteaching and learning situations. In Bolter and Grusin’s terminology, they are efforts of a ‘remediation’ of the original medium, e.g. the body, the hos-pital context and actual nursing (1999). The obvious challengewith a remediating approach, is how well it emulates the reality it is supposed to simulate. As Bradley notes, the process of making the remediation morelively, transparent and realistic is a result of continuallyrefined technology, both in terms of hardware and software, as well as didactical perfection from the human actors (2006). Nomatter how much the technology reduces the distance between the two modes of reality, there will still be a gap:

‘it’s a manikin lying there, yes you may spray the manikin with water and … you hear voices, but still you don’t get that clinical gaze you get when there is an actual person or real human body [...] how a normal human body will react. It’s all good with the manikins, but it’s not optimal still’ (Interview, 3rd. year student).

On the other hand, students also claim that theyeasily becomeimmersedwith the situation and get ‘hooked’ on the simulated‘reality’. Students have, probably, different approaches, or thresholds, for becoming immersedin such situations. This is a constant challenge for the teachers to identify.

While the simulation is taped, the tapesare not used for extra scrutiny or examinationof details, nor are transcripts or registers of pulse, temperature or othergraphicalinput used in the simulation debrief. The potential isobviouslythere for usingsuch approaches for detailed analysis of singularnursingacts. The teachersinvolved in the research and development of the simulation lab are testing out two strategiesthatmight be fruitful. One is producing a media story of a family, which isprovided with episodes of its well-being or illness, a story that will be applied to the different sections of their training throughout their three – or in this casefour–years of progression. A project has been designed, and an application to an external financing body (Norway Opening Universities) has been produced (Tosterud &

Bogsti, 2017). Making debriefingsmoreproductive has also beenidentified asan areaworth exploring by the same group. Based on the research provided by several professors(Tosterud, 2015) they will test out different approaches to perform the debriefing (Tosterud, 2017).

The catalogue ofcases is an important resource for the simulations. They contain scripts for what is likely to happen and which parameters might be altered to run the dramatic story-linetowards the desired goals ofthelearning situation.Compared withhow students assess otherteaching and learningactivities, the reflective seminar in simulation isdeemed to be of a highquality. Connecting the experiences gained in practicummoredirectly to the chosen case for simulation more directly is a possible improvement suggested by the students. For our own part, we would recommend a closerinvestigationinto what a narrativeapproach might add to the student’s learning, notonly aslogs or reflection notes from practicum (Al-vsvåg & Dahl, 2013), but by audiovisual means (Hardy & Sumner, 2014; Jamissen, Hardy, Nordkvelle, & Pleasants, 2017; Nordkvelle, Fritze, & Haugsbakk, 2017).

5.9 Conclusion and recommendations

The simulation is generally seen as a valuable addition to the practicumteaching and learning context. Students find the opportunity to have a distinctively active role intheir practicum very positive and are very satisfied with having teachers who have the courage to set up s im-ulationswhich canbeopen-ended and daring. Theyassess the method for their involvement to be challenging and arousing of emotions. Fear and awe of the situation is joined with the acceptance of theneedtofind a fluency in handling the complexity of the nursing situations.

The studentsfind the teachers to be careful in their runningoftheprocedures during simula-tions, andare strongly engagedintheirown thinking andreflectionabouttheirperformance, and how this links totheoretical knowledge and the standard wisdomofthe experienced nurse.

This case study affirms that students value the simulationas a daring and challenging learning situation. The quality of using simulations is linked to at least three dimensions:

• it makes itpossible tocutoutsingulartypical nursing situations, focus on its details and study it apart from other distracting features

• it generatessuspenseand sparks off a desire to perform wellboth for the student’s own sense of progression, but also for the collective of nursing students

• it caters for reflection by means of guided action, collective discussion,supervision and discourses of evidence-based nursing.

Student nurses think it adds value to their learning in practicum, primarily because it creates morespace for theoretical reflectionin an orderly manner, e.g. firstnoticing, then describing, thinking systematically and critically, seeking alternatives, screening literature and research.

The tension and anxiety of the students who act during simulations is a concern that is han-dled withcare. It is on the other hand strongly agreed that the experiencesareclose to reality and veryvaluable for thinking nursing through. The safeguarding of students and patients is obvious, and simulations with the kind of manikin and technological devicesemployed in this context encourage the student nurses involved to become immersedin the situation. The quality of the simulation depends on numerous factors, as said earlier, and the literature pr i-marily focus on the quality of the teacherinterventions, students, educationalpractices, and simulations design characteristics (Jeffries, 2005). In the case analysed we assess that the teachers (facilitator, operator) were highly attentive to student needs, unfolded their roles with sensitivity, provided a sophisticated mixofexperienceandtheoretical insights during debriefing, and maintained a positive and supportive tone during the entiresimulation. The students were actively involved, curious and attentive, and seemingly wellprepared for the simulation. The ‘acting’ during the simulations wasaffirming; mistakes madecaused no harm, but rather were welcomed aspoints of reflection and critique.During debriefing attention wasintense and constant. The dialogues and variety of instruction, questioning, reflection, and the use of mediashowed that theselectionofeducationalactivities waswide and com-prehensive. The simulation design seemed to be well proven and functioned well.

The simulationtakes place in a practicum period, where many disciplines in the nursing professional study come into place. Making the different subject areas join together is a vital factor for the students’ making sense of the topic. The emphasis onreflectiononaction, trial

and error of the simulation and the situations wherestudents are simulating on the one hand and trying out in practice on the other is the dominant activity.

Thiscaseshows us the benefits ofsimulation training. The interviews reveal interesting thoughts concerning how students define the simulationactivity. Students find simulation to be good theory lessons. We also learn that simulation requiresgood planning and students need a basicsimulation competence to get the full potential revealed in the case. An interest-ing factorinthe simulationis how much pressure the students tolerate intheactual simula-tion. Supervisors and facilitators tellusstories about students having a breakdownafter a

‘patient’ died insimulation.This leaves supervisorswithchallenges inhowfar they should go insimulation to make the students feel that they succeed and raise their self-efficacy. Allthis requires a lot of preparation andknowledge from supervisors, bothon the actualsimulation and the students aswell. The four most important aspects to understand quality insimulation, as suggested by Jefferies, are all displayed in the case. We have seen teacherscater for a situ-ation, going from roleto role: asfacilitator, supervisor, seminar leader and also teaching, per-forming assessment. The character of the teacher interventions was caring andcareful, mind-ful ofthestateof the students, adjusting theeducationalpracticeswith variation, and

‘patient’ died insimulation.This leaves supervisorswithchallenges inhowfar they should go insimulation to make the students feel that they succeed and raise their self-efficacy. Allthis requires a lot of preparation andknowledge from supervisors, bothon the actualsimulation and the students aswell. The four most important aspects to understand quality insimulation, as suggested by Jefferies, are all displayed in the case. We have seen teacherscater for a situ-ation, going from roleto role: asfacilitator, supervisor, seminar leader and also teaching, per-forming assessment. The character of the teacher interventions was caring andcareful, mind-ful ofthestateof the students, adjusting theeducationalpracticeswith variation, and