How Simulation might help us improve the vitally important but often understated self-efficacy needed to act as confident Healthcare Providers
Michael Sautter
Chief Learning Officer at Laerdal Medical | Host of the One million Lives Podcast
Who you think you are and what you think you can do, will determine what you do and how well you will do it.
Jenny and Max have been studying nursing together for two years. They enjoy working together on different assignments and are often found practising clinical skills and procedures in the lab with fellow students. Today, a large part of their cohort is gathered at the simulation lab to run teacher-facilitated patient cases related to communicating with geriatric patients and their families.
After the pre-brief, Jenny, Max, and two other students self-select to be the first team through the simulation. After the simulation, the teacher, Mary, starts the debrief. As is typically the case, Mary can see how the four students behave very differently during the debrief. Max and one of the other students are more than willing to share what went well and be vulnerable on what needs improvement. Mary carefully includes Jenny and the fourth student to elicit their thoughts about what had happened but senses that they are somewhat more reluctant to engage with openness and transparency.
Mary reflects on these differences in the students’ willingness to put themselves forward. There is no significant difference in the actual competencies demonstrated by these four. Furthermore, Jenny’s ability to listen carefully to what the “family members” were hinting at during the scenario was excellent, and, as it turns out, it helped Jenny catch on to something that was missed by the three others. But still, Jenny seems insecure and reluctant to believe that this situation was something she handled well.
The subjective nature of the opposing forces inside us
When confronted with a challenge, task, or assignment, most of us experience internal, opposing forces trying to influence how to proceed. Perhaps overly simplistically stated, the two major opposing pulls are the fear of failure and the desire to succeed in solving the challenge or task.
Recognising the subjective nature of our ongoing assessments in such situations and how the perceived risk-reward ratio plays a major part in what comes next is important. Our decisions are typically based on self-talk, and this self-talk always has roots in what the Canadian-born American psychologist Albert Bandura called Self-Efficacy. Para-phrased, and put slightly tabloid, he said “Who you think you are, and what you think you can do, will determine what you do, and how well you do it”.
So, not only is self-talk subjective, but this subjectiveness may also lead to decisions and behaviours that, when seen by another person, are hard to square with our more objective impression or even measures of that person’s competence or abilities.
Understanding the choices we make
When Mary observes Jenny and Max, two students from the same cohort and with very similar objectively measured competence, thinking so differently about their own performance, it begs the question of why this might be. How can such a difference be explained and, even more importantly, how might it be equalised?
This is a good time to consider what is known as the “Yerkes-Dodson Law”, which is actually less of a law than a psychological concept. Basically, the concept describes that one’s performance depends on the level of arousal when doing a task. If the task is too easy, or too difficult, the level of arousal is low. But under conditions perceived as ideal, the optimal arousal is awakened, and we perform optimally.
But while the Yerkes-Dodson bell curve helps us to understand that there may objectively be such a thing as an ideal situation that yields optimal arousal and, thus, helps us perform at our best, it still fails to help us understand why we see such differences in behaviours and motivation between people with comparable sets of objectively measured competencies.
But if we view the Yerkes-Dodson model overlayed by Bandura’s notion of self-efficacy, it may better help us understand what is at work. Combining the two concepts could look something like this:
On the vertical axis, we see the number of successes (north), or failures (south), as perceived by the person herself. The horisontal axis illustrates the difficulty of a task (low, medium or difficult), also as perceived by the person herself.
Here is the crux: Under the very same condition, a perceived medium-difficult task (compared to their objectively measured competence), two persons might react very differently depending on their previous success or failures on similar tasks. Where the medium-difficult task may be seen as "desirable difficulty" and activate maximum motivation (arousal) for one, the other who has previously experienced challenges or failures on similar tasks may activate maximum anxiety. The reason is that the person herself understands that this is something that she should be able to do and also understands that people around her also think that this is something she should be able to do. This creates an expectation that does not sit well in her mind given that she remembers how she has struggled or even failed on similar tasks before.
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The implications and potential for Simulation
With this in mind, Mary now understands better why her students sometimes perform and act so differently, and often not in accordance with her own perception of their competence level. She realises that while competence may be expressed in objective terms and measures, self-efficacy is highly subjective. She also realises that most of the tools in her educational toolbox are geared towards mastering objectively measurable competencies.
The point I am making in this article is that we may have overseen or understated the potential of simulation in helping improve important subjective factors like self-efficacy and confidence.
If this is a relevant and important problem to solve, and looping back to the model above, we are basically left with two choices: The first is to adjust or individualise what is defined as “medium difficult” in any healthcare education setting. This is not really a viable solution because when these students go to work on Monday after graduation, they will be met with clear expectations of what they should be able to do. If they come to work with less than expected competencies, they are not only of less use, they may even represent a danger to their patients.
The second choice is influencing the vertical axis to lift their perceived mastery of a situation or task. As we have already established, this directly influences whether they meet a medium difficult task with motivation or anxiety.
This is where simulation can directly, almost intravenously, inject self-efficacy. Done right, it can lift them from a state of uncertainty and risk aversion to a state where they have the motivation (arousal) to go hand-in-hand with their objectively measurable competence.
What does Simulation for Self-Efficacy look like?
Simulation for self-efficacy is not a different kind of simulation than simulation to improve competence. However, it may have to be organised differently, and it certainly entails mechanisms to account for subjectivity as well as objectivity.
Key features of simulation also targeting self-efficacy might be:
The main challenge in how most institutions have implemented simulation is the use of deliberate practice; the availability of repetitive, targeted practice in the simulation until mastery (and confidence) levels are reached. While I fully appreciate the logistical and time-related challenge in offering students the opportunity to repeat the same patient case/scenario multiple times, we should accept that this does not mean there is something wrong with our understanding of what will serve, or with simulation, but rather the we way we have organised around it.
Let's agree that allowing students enough simulation opportunities to experience competence and confidence is critically important. We then have to carefully consider new ways of organising our simulation activities in ways that break the link with time and space. If we remain in the "same time - space space" quadrant above, most colleges will have neither staff nor facilities to accommodate the need. But that is a topic for a forthcoming article.
Instead, we must explore modalities like self-paced procedure training, peer-to-peer simulation and similar to provide an allowance for improving the subjectively felt self-efficacy. Only then will we have competent and confident healthcare providers ready to take on the many challenges in today's healthcare.