Advertisement

The Missing Link: Cognitive Apprenticeship as a Mentorship Framework for Simulation Facilitator Development

Published:August 02, 2021DOI:https://doi.org/10.1016/j.ecns.2021.06.006

      Highlights

      • Clinicians or clinical educators may not have time for formal simulation facilitator education
      • Simulation Facilitators need mentorship to advance simulation and debriefing skills
      • A mentorship approach for simulation facilitator development is a feasible option.
      • The Cognitive Apprenticeship model can be utilized for SBE facilitator mentorship

      Abstract

      Increasingly, clinicians and clinical educators are using simulation-based education (SBE) as a valued educational modality within healthcare organizations. Typically, these facilitators have minimal time to dedicate to uninterrupted formal education and development. To enhance effective use of SBE, facilitators need learner centered opportunities that promote the development and sustainment of expert SBE skills, knowledge, attitudes and behaviors. Implementing a mentorship approach for facilitator development is a feasible option. This article proposes that the Cognitive Apprenticeship model (Collins et al., 1991) can be adapted and utilized for SBE facilitator mentorship.

      Keywords

      Key Points
      • Busy clinicians and clinical educators in healthcare organizations with minimal time for uninterrupted formal simulation facilitator development benefit from mentorship to enhance facilitation and debriefing expertise
      • Implementing a mentorship approach for facilitator development is a feasible option.
      • The Cognitive Apprenticeship model can be utilized for simulation based education facilitator mentorship.

      Background

      The use of simulation-based education (SBE) as an educational tool for professional development within healthcare organizations is growing (
      • Cheng A.
      • Grant V.
      • Dieckmann P.D.
      • Arora S.
      • Robinson T.
      • Eppich W.
      Faculty development for simulation programs: Five issues for the future of debriefing training.
      ). Within the healthcare context, SBE facilitators are generally busy clinicians or clinical educators who have numerous responsibilities and are unable to devote large amounts of time for participation in a formal faculty development program (
      • Kumar A.H.
      • Howard S.K.
      • Udani A.D.
      Tipping the scales: Prioritizing mentorship and support in simulation faculty development.
      ; McGaghie et al.,
      • McGaghie W.C.
      • Issenberg S.B.
      • Petrusa E.R.
      • Scalese R.J.
      A critical review of simulation-based medical education research: 2003–2009.
      ; Norquest & Sundberg,
      • Nordquist J.
      • Sundberg K.
      Institutional needs and faculty development for simulation.
      ). Typically, the clinicians or educators interested in SBE take a single introductory simulation workshop or course and then rely on their previous experience in simulation or peer coaching to further their knowledge and skills. Ongoing facilitation skills and faculty development is difficult due to competingdemands and time constraints (
      • McGaghie W.C.
      • Issenberg S.B.
      • Petrusa E.R.
      • Scalese R.J.
      A critical review of simulation-based medical education research: 2003–2009.
      ;
      • McIntosh P.
      • Freeth D.
      • Berridge E.J.
      Supporting accomplished facilitation: Examining the use of appreciative inquiry to inform the development of learning resources for medical educators.
      ;
      • Peterson D.
      • White M.
      • Watts P.
      • Epps C.
      Simulation faculty development: A tiered approach.
      ;
      • Sigalet E.L.
      • Davies J.L.
      • Scott E.A.
      • Brisseau G.F.
      • Shumway J.B.
      • Blackie B.J.
      Designing interprofessional simulation based faculty development in a new women and children's hospital in the Middle East: A pilot study.
      ). New facilitators need more than an introductory simulation facilitation course to strengthen facilitation and debriefing skills that transfer into practice; they need deliberate practice with reflective feedback (
      • Cheng A.
      • Grant V.
      • Dieckmann P.D.
      • Arora S.
      • Robinson T.
      • Eppich W.
      Faculty development for simulation programs: Five issues for the future of debriefing training.
      ).
      • Cheng A.
      • Eppich W.
      • Kolbe M.
      • Meguerdichian M.
      • Bajaj K.
      • Grant V.
      A Conceptual Framework for the Development of Debriefing Skills.
      further emphasizes that specific strategies are required to ensure that there is debriefing skill acquisition and retention (p. 59). While a proposed framework to develop debriefing skills is informative, it cannot be assumed that these skills are intrinsic (
      • Peterson D.
      • White M.
      • Watts P.
      • Epps C.
      Simulation faculty development: A tiered approach.
      ), or that clinical knowledge or experience alone guarantees effective SBE facilitation and debriefing skills (
      • McGaghie W.C.
      • Issenberg S.B.
      • Petrusa E.R.
      • Scalese R.J.
      A critical review of simulation-based medical education research: 2003–2009.
      ; Nordquest & Sundberg,
      • Nordquist J.
      • Sundberg K.
      Institutional needs and faculty development for simulation.
      ). Just as it requires specific skills to be an expert obstetrical or emergency clinician, quality SBE facilitation and debriefing requires specific skills, knowledge and behaviors, such as demonstration of simulation pedagogy, psychological safety, and effective use of recognized debriefing frameworks and strategies.
      • Gardner A.K.
      • Gee D.
      • Ahmed R.A.
      Perspective: Entrustable professional activities (EPAs) for simulation leaders: The time has come.
      and INACSL Standards Committee (
      INACSL Standards Committee
      INACSLstandards of best practice: simulation© debriefing.
      ) provide a detailed description of these skills.

      Mentorship

      For the purpose of this paper, mentorship is defined as the informal collaborative relationship that supports observation, individualized learning opportunities, expert feedback and experiential learning that develop the knowledge, skills, and behaviors required for simulation facilitators (
      • Gardner A.K.
      • Gee D.
      • Ahmed R.A.
      Perspective: Entrustable professional activities (EPAs) for simulation leaders: The time has come.
      ). Informal mentorship is about creating a nurturing relationship between a mentor and mentee, where learning needs, opportunities and objectives are customizable without set deadlines (
      • Kumar A.H.
      • Howard S.K.
      • Udani A.D.
      Tipping the scales: Prioritizing mentorship and support in simulation faculty development.
      ), as compared to a formal mentorship program with pre-established timelines limiting a busy clinician's participation due to clinical responsibilities and demands. Informal mentorship still includes coaching, deliberate feedback, as well encouraging new facilitators to pursue organized education.
      These informal mentorship relationships can be adapted to promote professional development and sustainability (
      • Kumar A.H.
      • Howard S.K.
      • Udani A.D.
      Tipping the scales: Prioritizing mentorship and support in simulation faculty development.
      ) for new healthcare SBE facilitators and should be considered over a formal faculty development program.
      • Gardner A.K.
      • Gee D.
      • Ahmed R.A.
      Perspective: Entrustable professional activities (EPAs) for simulation leaders: The time has come.
      clearly articulated that mentorship, along with proactive planning, assists clinicians with developing and demonstrating the necessary knowledge, skills and behaviors for high quality simulation facilitation. This includes knowledge of debriefing frameworks, foundational SBE theories and methodologies; skills that guide learners to reflect or manage challenging debriefings; attitudes and behaviors that demonstrate respect, genuine curiosity and openness to listen to learners (
      • Gardner A.K.
      • Gee D.
      • Ahmed R.A.
      Perspective: Entrustable professional activities (EPAs) for simulation leaders: The time has come.
      ; INACSL,
      INACSL Standards Committee
      INACSLstandards of best practice: simulation© debriefing.
      ). Faculty development around debriefing is key to maintaining and enhancing quality simulation and facilitators, but requires dedicated time and financial commitment (
      • Cheng A.
      • Grant V.
      • Huffman J
      • Burgess G.
      • Szyld D
      • Robinson T
      • Eppich W.
      Coaching the debriefer: Peer coaching to improve debriefing quality in simulation programs.
      ;
      • Cheng A.
      • Grant V.
      • Dieckmann P.D.
      • Arora S.
      • Robinson T.
      • Eppich W.
      Faculty development for simulation programs: Five issues for the future of debriefing training.
      ). The emphasis is on promoting ample opportunities to facilitate and sustain the debriefing and facilitation skills and support healthcare facilitators who juggle multiple responsibilities (
      • Kumar A.H.
      • Howard S.K.
      • Udani A.D.
      Tipping the scales: Prioritizing mentorship and support in simulation faculty development.
      ). Mentorship can support a new facilitator to master simulation facilitation and debriefing, where expertise or proficiency is seen as a process of building high quality simulation practice rather than identifying skill deficits (
      • McIntosh P.
      • Freeth D.
      • Berridge E.J.
      Supporting accomplished facilitation: Examining the use of appreciative inquiry to inform the development of learning resources for medical educators.
      ) or grading facilitators on a scale or checklist (
      • Steinert Y.
      • Mann K.
      • Anderson B.
      • Barnett B.M.
      • Centeno A.
      • Naismith L.
      • Dolmans D.
      A systematic review of faculty development initiatives designed to enhance teaching effectiveness: A 10-year update: BEME Guide No. 40.
      ).
      Currently, the eSIM Provincial Simulation Program, a provincial program within Alberta Health Services (AHS), is using SBE and providing education for simulation facilitators. The eSIM mandate is to educate, Simulate, Innovate and Motivate (eSIM) health professions educators to integrate SBE as an educational tool within the organization (,

      Alberta Health Services. (2017). eSIM Mentorship Checklist

      ,

      Alberta Health Services. (2017). WISE graduate survey report May 1, 2017.

      , ). The focus of the SBE is on team training, patient safety and improving processes and systems within the workplace. The eSIM simulation consultants currently offer a No-fee 2-day introductory facilitation course called WISE (Workshop in Simulation Education) for clinical educators and clinicians affiliated with AHS who want to use SBE as an educational tool in their environments. The course content incorporates a guided interactive and immersive learning experience focusing on simulation theory, effective teamwork, prebriefing and debriefing, scenario development and creating realism. Table 1 summarizes the course objectives. After completion of the WISE course, new facilitators are offered mentorship from simulation consultants.
      Table 1XXX Course Objectives
      To provide an experience that will allow participants to:
      • Understand the essential elements of a simulation session
      • Identifiy principles of effective team skills
      • Learn and apply tools for effective debriefing
      • Participate in scenario development
      • Facilitate a simulation scenario
      • Begin to utilize simulation as an educational tool
      Note. Reprinted from .

      Mentorship Gap

      The eSIM program recognized that mentorship, as a form of facilitator development, is a cornerstone for simulation facilitator development. However, there is a lack of literature about the long-term outcomes of effective simulation mentorship within healthcare organization simulation programs (
      • Cheng A.
      • Grant V.
      • Dieckmann P.D.
      • Arora S.
      • Robinson T.
      • Eppich W.
      Faculty development for simulation programs: Five issues for the future of debriefing training.
      ;
      • Kumar A.H.
      • Howard S.K.
      • Udani A.D.
      Tipping the scales: Prioritizing mentorship and support in simulation faculty development.
      ;
      • Steinert Y.
      Faculty development in the new millennium: key challenges and future directions.
      ). A challenge for the eSIM team is ensuring that new facilitators develop the necessary knowledge, skills and behaviors. Many new facilitators are not always able to use SBE within three months post-WISE course. Additionally, the simulation consultants acknowledge that cognitive fatigue (
      • Raman M.
      • McLaughlin K.
      • Violato C.
      • Rostom A.
      • Allard J.P.
      • Coderre S.
      Teaching in small portions dispersed over time enhances long-term knowledge retention.
      ; ), or the notion of, “if you don't use something, you lose it” may play a contributing role.
      As a healthcare organization with limited resources and busy facilitators, there was a need to reconsider how to support continual simulation facilitator development. One solution was to integrate ongoing mentorship as part of the commitment to new facilitators prior to participating in the initial WISE workshop. A proposed effective foundation and framework to build a sustainable simulation facilitator mentorship program was the cognitive apprenticeship model. The purpose of this paper is to describe the cognitive apprenticeship model and how the model applies to mentorship with novice simulation facilitators.

      Cognitive Apprenticeship Model

      Cognitive apprenticeship (CA) has roots in the traditional apprenticeship model, a centuries old method of teaching novice workers observable tangible (physical) skills in a specific trade (
      • Collins A.
      • Brown J.S.
      • Holum A.
      Cognitive Apprenticeship: Making Thinking Visible.
      ). Novices practiced and were provided guidance from an expert craftsman until they were independent (
      • Nickle P.
      Cognitive apprenticeship: laying the groundwork for mentoring registered nurses in the intensive care unit.
      ;
      • Collins A.
      • Brown J.S.
      • Holum A.
      Cognitive Apprenticeship: Making Thinking Visible.
      ). This model was adapted and applied to cognitive and metacognitive tasks, where complex cognitive skills are essential for advanced problem-solving skills (
      • Collins A.
      • Brown J.S.
      • Holum A.
      Cognitive Apprenticeship: Making Thinking Visible.
      ;
      • Lyons K.
      • McLaughlin J.E.
      • Khanova J.
      • Roth M.T.
      Cognitive apprenticeship in health sciences education: A qualitative review.
      ). Because it deals with learning cognitive tasks versus physical and observable tasks, both the learner and the teacher must share their thought processes and implicit knowledge with each other, ensuring that the specific learning task makes sense to the learner (
      • Collins A.
      • Brown J.S.
      • Holum A.
      Cognitive Apprenticeship: Making Thinking Visible.
      ). Cognitive apprenticeship recognizes that different types of knowledge are required for expertise. Strategic knowledge is the tacit or informal knowledge and experience that “underlies how experts make use of concepts, facts, procedures to solve problems or accomplish tasks” (
      • Collins A.
      • Brown J.S.
      • Holum A.
      Cognitive Apprenticeship: Making Thinking Visible.
      ). Expert problem-solving knowledge is usually comprised of heuristic tactics or ‘rules of thumb’ abilities (
      • Collins A.
      • Brown J.S.
      • Holum A.
      Cognitive Apprenticeship: Making Thinking Visible.
      ). This knowledge is situated in the context and culture in which it is learned, and to improve both skills and knowledge, contextualized practice is needed.

      Cognitive Apprenticeship Applied to Simulation Facilitator Mentorship

      • Nickle P.
      Cognitive apprenticeship: laying the groundwork for mentoring registered nurses in the intensive care unit.
      applied the cognitive apprenticeship model for mentorship of new Registered Nurses (RNs) in the Intensive Care Unit context where new ICU RNs were defined as mentees and expert ICU RNs were delineated as mentors. In this current article, the terms novice facilitator and simulation consultant will be used to define a mentee and mentor.
      Cognitive apprenticeship has four interconnected domains to apply to learning environments where learners require expertise of cognitive skills, (
      • Collins A.
      • Brown J.S.
      • Newman S.E.
      Cognitive apprenticeship: teaching the crafts of reading, writing and mathematics.
      ), such as mentorship for novice simulation facilitators. Each domain and method of the mentorship model is intended to guide the novice simulation facilitator towards the enculturation of high-quality simulation facilitation that ultimately impacts quality outcomes of safe patient care (
      • Nickle P.
      Cognitive apprenticeship: laying the groundwork for mentoring registered nurses in the intensive care unit.
      , p.24). The domains include content, method, sequencing and sociology. Table 2 describes the CA domains with application to simulation facilitator mentorship.
      Table 2Domains of Cognitive Apprenticeship Applied to Simulation Facilitator Mentorship
      ContentTypes of knowledge/strategies required for expertiseApplied to Mentorship
      DomainKnowledge subject matter specific concepts, facts, and proceduresAdult learning principles, WISE curriculum, debriefing, facilitation, teamwork
      Heuristic strategiesGenerally applicable techniques for accomplishing tasksPast SBE facilitation experiences, SBE do's & don'ts
      Control strategiesGeneral approaches for directing one's solution processDeliberate practice and reflection of debriefing, facilitation and scenario design
      Learning strategiesKnowledge about how to learn new concepts, facts, and proceduresDemonstration of effective facilitation and debriefing skills
      MethodTeaching strategies for promoting expertise
      ModelingTeacher performs a task so students can observeMentor models skills, knowledge, behaviors of prebrief, debriefing, co-debriefing
      CoachingTeacher observes and facilitates while students perform a taskIntentional feedback after prebrief, debrief
      ScaffoldingTeacher provides supports to help the student perform a taskMentor support/lead with facilitation and debriefing until the mentee has experience to lead
      ArticulationTeacher encourages students to verbalize their knowledge and thinkingMentor encourages deliberate reflection of debriefing
      ReflectionTeacher enables students to compare their performance with othersReflect on what went well, challenges, changes next time
      ExplorationTeacher invites students to pose and solve their own problemsMentee urged to transition into independent facilitation and debriefing
      SequencingKeys to ordering learning activities
      Global before local skillsFocus on conceptualizing the whole task before executing the partsExposure to SBE; WISE attendance before learning how to debrief or co-debrief
      Increasing complexityMeaningful tasks gradually increasing in difficultyLeading pre-brief before leading debriefing
      Increasing diversityPractice in a variety of situations to emphasize broad applicationFacilitating with nurses before leading interprofessional simulation
      SociologySocial characteristics of learning environments
      Situated learningStudents learn in the context of working on realistic tasksMentee able to use SBE in their clinical setting or for their needs
      Community of practiceCommunication about different ways to accomplish meaningful tasksSimulation Blogs, On-line Simulation Groups, Idea sharing times
      Intrinsic motivationStudents set personal goals to seek skills and solutionsMentee sees value of mentorship and wants to improve
      CooperationStudents work together to accomplish their goalsNurturing mentees to co-facilitate to advance healthcare simulation
      Note. Adapted from “Cognitive Apprenticeship: Making Thinking Visible” by A. Collins, J.S. Brown and A. Holum,
      • Collins A.
      • Brown J.S.
      • Holum A.
      Cognitive Apprenticeship: Making Thinking Visible.
      , American Educators, 6 (11), p.14-15.
      Content, or the types of knowledge and strategies required for expertise include domain, heuristic strategies, control strategies and learning strategies. Skilled SBE facilitators use underlying strategies, or strategic knowledge and abilities to effectively facilitate SBE and to mentor new facilitators (
      • Lyons K.
      • McLaughlin J.E.
      • Khanova J.
      • Roth M.T.
      Cognitive apprenticeship in health sciences education: A qualitative review.
      ). These different types of knowledge required for simulation expertise needs to be explicitly shared with a new facilitator. It is assumed that new facilitators come with tacit knowledge, such as ideas, perceptions and backgrounds based on their experiences in problem solving, education and clinical experiences and use this knowledge, both effective and unproductive, to build upon their facilitation of SBE (
      • Collins A.
      • Brown J.S.
      • Holum A.
      Cognitive Apprenticeship: Making Thinking Visible.
      ).
      Simulation facilitation mentorship requires skilled simulation consultants who have domain knowledge in adult learning principles, simulation facilitation & debriefing. For example, simulation experts need strategic, or tacit knowledge in mentoring, simulation principles and theory, facilitation strategies, teamwork principles, pre-briefing, scenario design and realism, simulation operations (manikins and simulated patient (SP)) training and most importantly, debriefing methods and strategies.
      Simulation mentorship requires skilled simulation consultants with simulation heuristic strategies, or ‘tricks of the trade’ approaches with facilitation. This tacit knowledge is acquired from skillful facilitation of SBE (
      • Collins A.
      • Brown J.S.
      • Holum A.
      Cognitive Apprenticeship: Making Thinking Visible.
      ). It is the behind the scenes planning and organization that happens before an actual session takes place, experience of creating a straight forward to more complex interprofessional scenario design and paying attention to realism, the art of navigating a difficult debriefing, or feeling confident with the do's & don'ts of debriefing. Novice facilitators can integrate this into their facilitation skills by observation and co-facilitating with a facilitator who uses these strategies. A novice simulation facilitator will not use heuristic strategies the same way as a skilled facilitator because they do not have the extensive experience with SBE facilitation (
      • Collins A.
      • Brown J.S.
      • Holum A.
      Cognitive Apprenticeship: Making Thinking Visible.
      ).
      The novice facilitator develops control strategies, as they develop heuristic problem-solving abilities. It is working with the simulation consultant to create suitable scenarios, practice debriefing and reflecting on these experiences to continually expand or modify facilitation skills. The more a new facilitator practices advocacy inquiry debriefing, the more proficient they will become with it.
      The novice facilitator establishes learning strategies to facilitate and debrief effectively. Having observed how others facilitate and then co-facilitating with a simulation consultant are able to demonstrate effective facilitation and use a variety of debriefing methods to debrief teamwork and clinical skills. It is the ability to process, apply feedback from a simulation consultant, and self-reflect that improves debriefing skills.
      Method, or the teaching strategies for developing simulation facilitation expertise provide new simulation facilitators the opportunity to observe, engage and learn expert simulation and debriefing strategies (
      • Collins A.
      • Brown J.S.
      • Holum A.
      Cognitive Apprenticeship: Making Thinking Visible.
      ). The methods include modeling, coaching, scaffolding/fading, articulation, reflection, and exploration. These are foundational to CA, as they are designed to help novice facilitators assimilate simulation facilitation skills through the process of observation and guided practice.
      Modelling is a constant process. The simulation consultants model the skills, knowledge and behaviors of facilitation and debriefing what they want new facilitators learn during the WISE course, as well as during simulation facilitation. During simulation sessions, a simulation consultant will lead everything from the prebrief, to scenario, debrief and summary phase. They will model different debriefing methods and how to co-debrief an effective simulation session. A simulation consultant intentionally articulates and clarifies their ‘frames’ or rationale for their actions and thought processes (heuristic strategies).
      Coaching occurs as a new facilitator is actively engaged in the development and experience of simulation facilitation. A significant amount of time can be spent on coaching. A simulation consultant needs to coach and provide feedback, while being in tune to the needs of a new facilitator to see when they are able to take on greater roles in mastering simulation facilitation (
      • Kumar A.H.
      • Howard S.K.
      • Udani A.D.
      Tipping the scales: Prioritizing mentorship and support in simulation faculty development.
      ). Coaching occurs during scenario design, as well as before and after facilitation and debriefing. A simulation consultant observes and provides feedback on effectiveness of the pre-brief and scenario, as well as highlights complex concepts and/or knowledge gaps with debriefing methods (
      • Cheng A.
      • Grant V.
      • Huffman J
      • Burgess G.
      • Szyld D
      • Robinson T
      • Eppich W.
      Coaching the debriefer: Peer coaching to improve debriefing quality in simulation programs.
      ). Post-simulation, the new facilitator shares what went well, challenges, or facilitation strategies utilized. A simulation consultant provides authentic intentional feedback on a new facilitator's feedback.
      Scaffolding and fading refer to the amount of support or parts of the simulation facilitation that a skilled facilitator performs that a novice facilitator cannot yet achieve (
      • Collins A.
      • Brown J.S.
      • Holum A.
      Cognitive Apprenticeship: Making Thinking Visible.
      ), such as leading a difficult debrief or debriefing a scenario where multiple health professions (i.e. interprofessional) are participating. The simulation consultant's leading role begins to decrease or fade as the new facilitator becomes more independent. As a new facilitator gains more knowledge and experience, more of the facilitation components are transferred to them. A new facilitator becomes the lead facilitator of the scenario, pre-brief and debrief. A simulation consultant still co-facilitates or co-debriefs but supports a new facilitator only as needed. Fading increases as a novice facilitator gains experience and becomes more confident.
      Articulation, reflection and exploration are the focus as novice facilitators gain their own expertise, using and applying the skills to master facilitation and the essence of debriefing, and personal ownership of simulation facilitation/debriefing skills. The method of articulation and reflection are woven into the entire mentorship. A novice facilitator is encouraged to intentionally verbalize their experience with facilitation and debriefing while analyzing and reflecting on their own skills, knowledge and behaviors as a facilitator. The structure of reflection is around what went well, the challenges, and opportunities for development to apply to future facilitation. Reflection involves exploring with a new facilitator how the Promoting Excellence and Reflective Learning in Simulation (PEARLS) healthcare debriefing tool was imbedded into their debriefings (
      • Bajaj K.
      • Meguerdichian M.
      • Thoma B.
      • Huang S.
      • Eppich W.
      • Cheng A.
      The PEARLS Healthcare Debriefing Tool.
      ). The more intentional and deliberate the articulation and reflection, the more likely, the skills, knowledge and behaviors of simulation facilitation and debriefing transfer into practice for a simulation facilitator. Exploration involves transitioning a facilitator to become independent with SBE, where they mirror true independence and leadership with both facilitation and debriefing skills, such as developing expertise using the PEARLS healthcare debriefing tool (
      • Bajaj K.
      • Meguerdichian M.
      • Thoma B.
      • Huang S.
      • Eppich W.
      • Cheng A.
      The PEARLS Healthcare Debriefing Tool.
      ). They are able to independently lead interprofessional simulation or mentor a new facilitator using the simulation skills, knowledge and behaviors learned.
      Independence is measured through guided self-reflection and deliberate feedback during pre and post simulation conversations with a simulation consultant and novice facilitator. Two accepted instruments guide these conversations. They are the Facilitator Competency Rubric (FCR) (

      Facilitator Competency Rubric (2018). Evaluating healthcare simulation. Available at: https://sites.google.com/view/evaluatinghealthcaresimulation/home

      ) and the Debriefing Assessment of Simulation Healthcare (DASH Tool) (

      Simon, R., Raemer, D.B., & Rudolph J.W. (2012). Debriefing Assessment for Simulation in Healthcare (DASH) Center for Medical Simulation, Boston, Massachusetts. Available at: https://harvardmedsim.org/wpcontent/uploads/2016/10/DASH_IV_LongForm_2012_05.pdf

      ).
      The sequencing domain provides a structured approach to learning that enable novice facilitators to transfer the simulation facilitation skills, knowledge and behaviors into their own facilitation (
      • Collins A.
      • Brown J.S.
      • Holum A.
      Cognitive Apprenticeship: Making Thinking Visible.
      ). Global before local skills supports the concept of providing a sequence of foundational simulation facilitation skills, knowledge and behaviors for novice facilitators so that they can develop and transfer this learning to specific skills needed (
      • Collins A.
      • Brown J.S.
      • Holum A.
      Cognitive Apprenticeship: Making Thinking Visible.
      ). New facilitators benefit from first being exposed to SBE, then attending WISE to observe the whole facilitation process then begin to practice the ‘tasks’ of facilitation. Increasing complexity involves taking on more and more of the skills that an expert facilitator does. It starts with basic, foundational skills that are easier to acquire first, such as using a predesigned scenario, leading the pre-brief and the debriefing reaction phase. Once confident and experienced with these skills, then begin to create scenarios and begin to co-debrief specific subjects using PEARLS debriefing principles (
      • Bajaj K.
      • Meguerdichian M.
      • Thoma B.
      • Huang S.
      • Eppich W.
      • Cheng A.
      The PEARLS Healthcare Debriefing Tool.
      ). Increasing diversity involves straight forward scenarios with uniprofessional groups, to facilitating with interprofessional teams, or taking leadership with difficult debriefs.
      The Sociology includes situated learning, community of practice, intrinsic motivation and cooperation (
      • Collins A.
      • Brown J.S.
      • Holum A.
      Cognitive Apprenticeship: Making Thinking Visible.
      ). It is about cultivating a learning environment or mentorship opportunities that motivate facilitators towards excellence. Situated learning is the collaborative relationship between a mentor and mentee, where the actual planning, facilitation and debriefing components of simulation are conducted. It is about creating a learning environment conducive for developing simulation facilitation skills that enable SBE within their clinical setting for their needs. Community of practice (CoP) involves supporting active sharing of simulation experiences, ideas, successes and challenges with others simulation facilitators for development of skills, knowledge and behaviors. It involves following simulation blogs or on-line simulation groups, as well as creating informal or formal times of sharing of ideas to learn from others. Promoting intrinsic motivation where learners want to improve both facilitation and debriefing skills is significant to continued use of SBE and facilitation. It is supported by developing an authentic rapport with a novice facilitator or deliberate feedback after both successful and frustrating simulation sessions. Fostering cooperation involves nurturing facilitators who can collaborate to support the advancement of simulation-based educational opportunities in healthcare settings.
      Using this model should enable a novice facilitator to gain general skills through first observing facilitation and debriefing, to gradual co-facilitation of specific components guided directly with a mentor, then to co-debriefing where the new facilitator is the lead debriefer with the simulation consultant guiding only as needed, to the transfer of total independence leading an entire SBE session. Ultimately, a mentee can apply this skills, knowledge and behaviors to any SBE or experiential learning opportunity.
      There are four assumptions in order for this model to be effective as mentorship for simulation facilitators. First, organizational commitment (
      • Nickle P.
      Cognitive apprenticeship: laying the groundwork for mentoring registered nurses in the intensive care unit.
      ) endorses simulation consultants to dedicate time to mentorship and mentees to participate. Second, all mentors possess well-developed simulation and debriefing skills, knowledge and behaviors to mentor, as well as knowledge of the mentorship model and strategies. It also includes tacit and explicit knowledge of adult learning principles and experiential learning. Three, the mentorship relationship is a collaborative dialogue and interaction for both the mentor and mentee with established expectations and guidelines clearly communicated for both (
      • Nickle P.
      Cognitive apprenticeship: laying the groundwork for mentoring registered nurses in the intensive care unit.
      ). Finally, mentorship is a psychologically safe environment for learning (
      • Rudolph J.W.
      • Raemer D.B.
      • Simon R.
      Establishing a safe container for learning in simulation.
      ). The novice facilitator can speak up about what one thinks, reflecting on challenges or mistakes, while experimenting and practicing the new skills they are learning without fear of being shamed, intimidated or humiliated (
      • Rudolph J.W.
      • Raemer D.B.
      • Simon R.
      Establishing a safe container for learning in simulation.
      ).

      Now what….Implementing Simulation Facilitation Mentorship

      The following are five implementation suggestions that can be tailored for a novice facilitator post an introductory SBE facilitation course, such as WISE, and are grounded in the CA model, with the emphasis on debriefing skill development and retention (
      • Cheng A.
      • Eppich W.
      • Kolbe M.
      • Meguerdichian M.
      • Bajaj K.
      • Grant V.
      A Conceptual Framework for the Development of Debriefing Skills.
      ). They are multidimensional and characterized as bursts of time learning opportunities. Table 3 provides an example of a checklist. They include the following:
      • 1)
        Transparent expectations and timelines for a new facilitator and simulation consultant outlined in a checklist which is negotiated at the start of the mentorship relationship. This provides a foundation for sequencing of the facilitation and debriefing skills.
      • 2)
        Co-facilitation with a simulation consultant for 3-10 sessions until prepared to lead all of the facilitation domains. Co-facilitation is intentionally structured to promote modeling, coaching and scaffolding and/or fading of facilitation and debriefing skills. For example, a simulation consultant will lead the more complex skill of debriefing and have the novice facilitator lead the prebrief and the reaction phase of a debrief. As a new facilitator's skill and confidence increases with these components, they will take lead with co-debriefing specific topics in addition to doing the prebrief.
      • 3)
        Seeking individualized self-reflection with feedback opportunities promotes intrinsic motivation that enhances reflection and exploration (
        • Gardner A.K.
        • Gee D.
        • Ahmed R.A.
        Perspective: Entrustable professional activities (EPAs) for simulation leaders: The time has come.
        ). This includes individualized debriefing opportunities based on the needs of the novice facilitator. This can be from a simulation consultant or other simulation expert. For example, it can be as simple as a facilitator either audio or video recording a scenario or debriefing and self-reflecting, then setting up a time with a simulation consultant for reflection and feedback.
      • 4)
        Participation in self-directed learning reinforces learning strategies, furthers exploration, situated learning and cooperation (
        • Gardner A.K.
        • Gee D.
        • Ahmed R.A.
        Perspective: Entrustable professional activities (EPAs) for simulation leaders: The time has come.
        ). This includes accessing expert simulation healthcare resources who are committed to improving safety and quality healthcare education. Examples of resources committed to advancing simulation knowledge through evidence informed collaborative research include the Debrief2learn https://debrief2learn.org online network and the Centre for Medical Simulation.
      • 5)
        Access to a simulation Community of Practice (CoP) network of simulation leaders and peers (
        • Gardner A.K.
        • Gee D.
        • Ahmed R.A.
        Perspective: Entrustable professional activities (EPAs) for simulation leaders: The time has come.
        ) promotes the sociology of a simulation mentorship environment. The goal of the CoP is to promote deliberate practice and reflection of debriefing strategies or other facilitation domains. The focus is on sharing common simulation facilitation challenges and successes related to skills and knowledge such as difficult debriefing, co-debriefing, or using PEARLS effectively. An example of a large online simulation community is Debrief2learn https://debrief2learn.org/ that has research, resources and podcasts that simulation facilitators can access anytime, although it is not designed to provide conversational dialogue among facilitators. An example of a small scale CoP involves incorporating regularly scheduled simulation webinar sessions with a simulation consultant and other facilitators to share and practice specific simulation and debriefing skills as well as receive deliberate feedback. Each session has a specific topic and attendees can send in questions, such as sharing a difficult debrief. The strength of this CoP is the ability to reinforce learning, as well as learn from other simulator facilitators.
      Table 3WISE Mentorship Checklist
      Pre-Mentorship

      • Observation in simulation and debriefing session pre-WISE (minimum 2)

      • Attend WISE Course and/or ensure you have applied to attend

      • Contact eSIM Simulation Program Consultant

      • Obtain and read Mentorship Program Package

      • Arrange Orientation Training with your eSIM faculty member

      • Ensure that you are familiar with the booking process and activity reporting

      1 week before the Trial Run Session

      • Send your completed scenario to your eSIM Simulation Program Consultant for feedback

      The Trial Run Session

      • Ensure enough of your team members are present to run through your scenario, including confederates, mannequin operator and de-briefers

      • Mannequin training (ensure that you have read your manikin training package prior to this trial run)

      Simulation Session 0-3

      • Learn to perform a thorough pre-brief

      • Act as a co-de-briefer for your scenario

      • Act as the medical content expert for your scenario (or ensure the presence of a content expert)

      • Learn to transport, set-up and take down the mannequin for your session

      Simulation Session 3-8

      • Learn to operate the mannequin for your session (mannequin training package and/or book with faculty)

      • Act as a co-de-briefer for your scenario and consider being the lead de-briefer

      Session 3-10

      Act as a lead de-briefer for your session and continue to be the content expert for your scenario

      Ongoing Mentorship

      • CoP

      • Self-directed learning

      https://debrief2learn.org/resources/

      https://harvardmedsim.org/resources/

      http://www.royalcollege.ca/rcsite/ppi/courses/simulation-health-care-video-series-e

      • Self-reflection/feedback

      • Contact the eSIM Consultant at any time for support
      Note. Reprinted from AHS eSIM Mentorship Checklist, Alberta Health Services, 2017. .

      Conclusion

      By implementing a simulation facilitation mentorship model grounded in cognitive apprenticeship, healthcare facilitators can be supported to develop the essential skills, knowledge, attitudes and behaviors to effectively and independently use SBE. The mentorship relationship needs to focus on creating a learning environment where the mentee is engaged and motivated to learn. A mentorship relationship is more than constructing a program that demands significant uninterrupted time and deadlines. Rather, it is about creating personalized learning opportunities that inspire a mentee to continually sharpen their current SBE facilitation and debriefing skills and knowledge.
      As healthcare simulation continues to grow, so will the need for skilled facilitators. More work is needed to research the unique needs of simulator facilitators and the implementation of facilitation mentorship grounded in cognitive apprenticeship model. Additionally, the identification of the sustainable long term SBE mentorship strategies requires further research.

      Acknowledgments

      The authors thank and acknowledge the eSIM team for their continued collaboration and support of simulation facilitators and the mentorship program. This work was completed as part of the graduate study final project requirements.

      References

      1. Alberta Health Services. (2017). eSIM Mentorship Checklist

      2. Alberta Health Services. (2017). WISE graduate survey report May 1, 2017.

      3. Alberta Health Services (2018). Retrieved from: https://www.albertahealthservices.ca/about/about.aspx

        • Bajaj K.
        • Meguerdichian M.
        • Thoma B.
        • Huang S.
        • Eppich W.
        • Cheng A.
        The PEARLS Healthcare Debriefing Tool.
        Academic Medicine: Journal of the Association of American Medical Colleges. 2018; 93: 336https://doi.org/10.1097/ACM.0000000000002035
        • Bartle N.
        Shifting the Curve.
        Training & Development (1839-8561). 2014; 41 (Available at:): 26-27
        • Cheng A.
        • Eppich W.
        • Kolbe M.
        • Meguerdichian M.
        • Bajaj K.
        • Grant V.
        A Conceptual Framework for the Development of Debriefing Skills.
        Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare. 2020; 15: 55-60https://doi.org/10.1097/SIH.0000000000000398
        • Cheng A.
        • Grant V.
        • Dieckmann P.D.
        • Arora S.
        • Robinson T.
        • Eppich W.
        Faculty development for simulation programs: Five issues for the future of debriefing training.
        Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare. 2015; 10: 217-222https://doi.org/10.1097/SIH.0000000000000090
        • Cheng A.
        • Grant V.
        • Huffman J
        • Burgess G.
        • Szyld D
        • Robinson T
        • Eppich W.
        Coaching the debriefer: Peer coaching to improve debriefing quality in simulation programs.
        Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare. 2017; 12: 319-325https://doi.org/10.1097/SIH.0000000000000232
        • Collins A.
        • Brown J.S.
        • Holum A.
        Cognitive Apprenticeship: Making Thinking Visible.
        American Educator. 1991; 6: 38-46
        • Collins A.
        • Brown J.S.
        • Newman S.E.
        Cognitive apprenticeship: teaching the crafts of reading, writing and mathematics.
        in: Resnick L.B. Knowing, learning and instruction: Essays in honor of Robert Glaser. Lawrence Erlbaum Associates, Hillsdale, NJ1989: 453-494
      4. Facilitator Competency Rubric (2018). Evaluating healthcare simulation. Available at: https://sites.google.com/view/evaluatinghealthcaresimulation/home

        • Gardner A.K.
        • Gee D.
        • Ahmed R.A.
        Perspective: Entrustable professional activities (EPAs) for simulation leaders: The time has come.
        Journal of Surgical Education. 2018; 75: 1137-1139https://doi.org/10.1016/j.jsurg.2018.03.003
        • INACSL Standards Committee
        INACSLstandards of best practice: simulation© debriefing.
        Clinical Simulation in Nursing. 2016; 2: S21-S25https://doi.org/10.1016/j.ecns.2016.09.008
        • Kumar A.H.
        • Howard S.K.
        • Udani A.D.
        Tipping the scales: Prioritizing mentorship and support in simulation faculty development.
        Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare. 2018; 72https://doi.org/10.1097/SIH.0000000000000275
        • Lyons K.
        • McLaughlin J.E.
        • Khanova J.
        • Roth M.T.
        Cognitive apprenticeship in health sciences education: A qualitative review.
        Advances in Health Sciences Education. 2017; 22: 723-739https://doi.org/10.1007/s10459-016-9707-4
        • McGaghie W.C.
        • Issenberg S.B.
        • Petrusa E.R.
        • Scalese R.J.
        A critical review of simulation-based medical education research: 2003–2009.
        Medical Education. 2010; 44: 50-63https://doi.org/10.1111/j.1365-2923.2009.03547.x
        • McIntosh P.
        • Freeth D.
        • Berridge E.J.
        Supporting accomplished facilitation: Examining the use of appreciative inquiry to inform the development of learning resources for medical educators.
        Educational Action Research. 2013; 21: 376-391https://doi.org/10.1080/09650792.2013.815044
        • Nickle P.
        Cognitive apprenticeship: laying the groundwork for mentoring registered nurses in the intensive care unit.
        Dynamics. 2007; 18 (Available at:): 19-27
        • Nordquist J.
        • Sundberg K.
        Institutional needs and faculty development for simulation.
        Best Practice & Research Clinical Anaesthesiology. 2015; 29: 13-20https://doi.org/10.1016/j.bpa.2015.02.001
        • Peterson D.
        • White M.
        • Watts P.
        • Epps C.
        Simulation faculty development: A tiered approach.
        Simulation in Healthcare. 2017; 12: 254-259https://doi.org/10.1097/SIH.0000000000000225
        • Raman M.
        • McLaughlin K.
        • Violato C.
        • Rostom A.
        • Allard J.P.
        • Coderre S.
        Teaching in small portions dispersed over time enhances long-term knowledge retention.
        Medical Teacher. 2010; 32: 250-255https://doi.org/10.3109/01421590903197019
        • Rudolph J.W.
        • Raemer D.B.
        • Simon R.
        Establishing a safe container for learning in simulation.
        Simulation in Healthcare: Journal of the Society for Simulation in Healthcare. 2014; 9: 339-349https://doi.org/10.1097/SIH.0000000000000047
        • Sigalet E.L.
        • Davies J.L.
        • Scott E.A.
        • Brisseau G.F.
        • Shumway J.B.
        • Blackie B.J.
        Designing interprofessional simulation based faculty development in a new women and children's hospital in the Middle East: A pilot study.
        Journal of Taibah University Medical Sciences. 2016; 11: 594-600https://doi.org/10.1016/j.jtumed.2016.10.010
      5. Simon, R., Raemer, D.B., & Rudolph J.W. (2012). Debriefing Assessment for Simulation in Healthcare (DASH) Center for Medical Simulation, Boston, Massachusetts. Available at: https://harvardmedsim.org/wpcontent/uploads/2016/10/DASH_IV_LongForm_2012_05.pdf

        • Steinert Y.
        Faculty development in the new millennium: key challenges and future directions.
        Medical Teacher. 2000; 22: 44-50https://doi.org/10.1080/01421590078814
        • Steinert Y.
        • Mann K.
        • Anderson B.
        • Barnett B.M.
        • Centeno A.
        • Naismith L.
        • Dolmans D.
        A systematic review of faculty development initiatives designed to enhance teaching effectiveness: A 10-year update: BEME Guide No. 40.
        Medical Teacher. 2016; 38: 769-786https://doi.org/10.1080/0142159X.2016.1181851