Research Article: Lessons for simulation-based education from social psychology

Date Published: February 23, 2016

Publisher: BioMed Central

Author(s): Ronnie J. Glavin.


Effective practice is informed by underlying theoretical models. Better awareness and understanding of such models can enhance reflection by practitioners on their current educational activities and so help drive the cycle of continuing improvement. In this article the author reflects on three ways in which a better understanding of social psychology gave insights into why some practices appeared to be more effective than others and some ways in which future practice could be altered. Social psychology places great emphasis on the importance of the situation in which people find themselves an how this impacts on their subsequent behaviour. The three areas specifically addressed in the article include factors which motivate and drive human activities, especially the importance of self-esteem. Secondly, the relevance of the fundamental attribution error, which looks at our tendency as humans to ascribe personal attributes as the cause of the behaviour of others rather than the influence of external events. The third area to be explored is the role of acquiring scripts or heuristics that can broaden the range of activities than can be performed at a subconscious or intuitive level. For each concept, the author has included a brief illustration of its application to the practice of a simulation educator.

Partial Text

In this article I would like to explore the ways in which some concepts from social psychology have helped me develop my roles as a teacher in both clinical and simulation-based education. 1

I began my medical career in 1978 and throughout my anaesthetic training became increasingly interested in medical education. While working as a consultant anaesthetist I graduated as a Master of Philosophy in Educational Studies in 1993. My dissertation looked at the development of educational material that could help promote the values linked to patient safety within the UK anaesthetic training framework. In 1997 I was appointed as an Educational Co-Director to the Scottish Clinical Simulation Centre, which became active in early 1998. At this time the centre began a long and successful collaboration with Professor Flin of the Department of Industrial Psychology of the University of Aberdeen. My interest in psychology had been kindled during my M.Phil course and now, with more direct access to the world of industrial psychology I continued to read around psychology but in a relatively unstructured fashion.

A very simple linear narrative of psychology and motives could begin with Freud thinking about how various subconscious desires influenced our behaviours, and how our brains kept these in some sort of balance to allow humans to function in co-operative society; the relative roles of the id, the ego and the superego. These motives or drives were thought of as internal [3]. The next group to formally study drives were the Behaviourists [3], who wanted to take a more objective, positivistic approach to the response of organisms to stimuli. Luminaries of this group, such as B.F. Skinner, viewed the brain as a ‘black box’ that could not be examined directly. However, by presenting animals with stimuli, positive or negative, one could study such factors as the strength or duration or frequency of stimuli on the response of the test subjects. That response could be measured in terms of how quickly it was achieved, how quickly it dissipated and the impact of subsequent reinforcement of the initial stimulus. The behaviourists relied on some internal driver, such as hunger, to provide a motive for their subjects: hungry rats would be encouraged to find a route through a maze to locate a piece of food. They did not deny the existence of internal motives, the held the view that proper scientific study of the workings of the ‘black box’ was not possible at that time.

A simple definition of psychology is ‘the scientific study of behaviour and the mind’ the term ‘mind’ can be substituted by the term ‘mental processes’ [3]. Social psychology is defined as ‘the scientific investigation of how the thoughts, feelings and behaviours of individuals are influenced by the actual, imagined or implied presence of others’ [8]. I would like to illustrate this definition by describing a famous experiment – The Good Samaritan Study [9]. In this study students at a New England seminary were allocated into two groups. Group A were asked to give a short talk on life in a seminary, while those in Group B were asked to give an account of the parable of the Good Samaritan. Half of each group were informed that they were running late and should hurry over to the lecture theatre; the other half was informed that they had some time but should go over early to ensure that everything was prepared. During the walk to the lecture theatre each student encountered a confederate of the investigators simulating a medical emergency. The investigators measured a number of variables for each group but found that the factor that had most impact on the behaviour of the students in terms of whether they would offer assistance or not was the perception of being early or late. Only ten per cent of the ‘late’ group offered assistance whereas over sixty per cent of the ‘early’ group offered assistance. This study, and others of a similar nature suggest that the situation a person perceives them self to be in has a much greater impact on their behaviour than other predisposing factors, such as knowledge, personality attributes etc. Social psychology studies how external factors can interact with an individual’s internal drivers. I would like to explore three concepts in further detail: self esteem, the fundamental attribution error and scripts and heuristics. I have chosen these three because they had the biggest impact on changes that I made to my own practice and because they helped me to explain some of my actions to other simulation centre faculty members. I shall begin with self esteem.

Self esteem can be thought of as our sense of self worth and in the educational realm can be thought of in terms of a ‘need for competence’ [4]. One could speculate that the seminary students wanted to be regarded positively; for those in the ‘late’ group the thought of being even later for the lecture could clash with that sense of positive regard. Maslow’s hierarchy refers to self-esteem in level 4 but I argue that in the context of professionals their identification of self with the professional role is also consistent with self-actualisation. Indeed, it is some of the limitations of my use of Maslow’s hierarchy in my practice that encouraged me to adopt other theoretical models. In the early days of simulation based education experiences a recurring scenario played out. Individuals holding important educational posts in Scottish Anaesthesia would ask if they could attend and observe. This was always accompanied by the phrase “you won’t make me do a scenario, will you?” I asked why and came to realise that the threat to their sense of professional status was so great that they were not prepared to put it to the test. Experienced professionals who do undertake scenario based education may change their behaviour to minimise this risk to their need for competence. They may play the game of ‘spotting’ the scenario, they may blame external factors; “It didn’t look real”, “It didn’t behave the way it should have”. We have all heard these comments, especially if things have not worked out so well during the scenario. So this is a very real concept and one of the approaches I found helpful came from reading Carol Dweck’s work on positive psychology [10]. Dweck describes a study in which primary school age children were given a problem in mathematics to solve. Some of the group were told that they were very good at mathematics and had above average mathematical ability. Other members of the group were told that they were very hard working and had above average levels of persistence. When the group were presented with further problems those in the ‘above average mathematical ability’ group were more reluctant to tackle them than those from the ‘above average persistence’ group. Dweck argued that the ‘above average mathematical group’ had more to lose because if they didn’t solve the problems then their self esteem as better mathematicians would be challenged. The more persistent group had nothing to lose because failure to solve the problem would not negate their self-esteem. Dweck refers to the ‘above average at maths’ mindset as a fixed mindset in contrast to the ‘above average at persistence’ mindset as a growth mindset. What Dweck did was to reframe the mindset from a fixed one to a growth one and I found this concept very helpful when dealing with experienced professionals in scenario based simulation. I explored some notions of professionalism with the group during the introduction session and from the discussion made the explicit statement that professionalism includes the desire to improve one’s professional performances (consistent with self-actualisation) and this means being able to learn from one’s performance. The focus of the course moves from concentrating on individual performance, without ignoring that component, to thinking about strategies that may work in future clinical encounters. This is explored further in the Vignette in Additional file 1.

The next area I want to explore is the Fundamental Attribution Error [8] (FAE). I shall illustrate with a fictitious example. Let us imagine that Person A is spending the first day in a new healthcare job. This job is similar to one previously held by that person in a different location. At a break Person A’s new colleagues ask the individual to join them for lunch. After a few minutes Person A does join the others. During the meal Person A neither joins readily in conversation nor appears to following those topics of conversation discussed by the others. Person A leaves the lunch table ten minutes before the others without comment. The new colleagues agree that Person A appears to be aloof and unfriendly, almost to the point of being antisocial. However, another colleague who had met Person A previously, expresses surprise and states that such behaviour was not typical from previous encounters. Indeed, Person A was lively, attentive and very popular with colleagues. How might we explain this discrepancy? This colleague talks to Person A and discovers that Person A was up most of the night with a sick child, who required hospital admission but is now in a stable condition. Person A chose to come to work because it was the first day and Person A’s spouse could be present in hospital with the child. On the way to work Person A was also involved in a minor road traffic accident, resulting in no personal harm but a future garage repair bill is likely. So which is the real Person A? Is person A the quiet, aloof, retiring individual or the lively, friendly and attentive individual? What is different? Well the circumstances are different and when we learn of Person A’s predicament we are much more likely to be understanding of Person A’s behaviour at lunch time. So the FAE consists of attributing behaviour to personal predispositions, such as personality factors, rather than attributing the circumstances in which an individual finds them self. As we have seen previously social psychology suggests that the circumstances, the situation, has a much more important bearing on behaviour than the personal characteristics of the individual.

The final concept I mentioned was the use of Scripts and Heuristics. This is a very big area in medical education just now and follows on the work of Kahneman and Twersky [13]. Heuristics are rules of thumb that we have developed which allow us make better use of our subconscious mind – described as fast thinking. I think of scripts as a subset of heuristics. The key features of a script are firstly that actors know what they are supposed to do and say and secondly that there are cues letting the actors know when they are expected to respond or react. Social Psychologists often use the restaurant script as an example. A typical example may go like this.Customer – “we have a table booked for 7 pm under the name of Smith”Restaurant staff – having checked bookings list “Come this way, here are the menus, the waiter will tell you about the specials”Front of House Staff – “Can I get you something to drink”Customer – “Can I see the wine list?”Etc.

The person and the situation summarises the main thrust of what social psychology is all about. We create situations when we create scenarios in our simulation roles. As health care professionals we have considerable ability and opportunity to influence the behaviours of our learners and to help them learn by facilitated reflection of such behaviours. As humans our behaviours are complex because not only do we each vary in sensitivity to those factors that may provoke a pattern of behaviour but the very patterns themselves will be influenced by factors such as cultural conditioning and personality dispositions. This is not intended to be a comprehensive review of social psychology but I hope that I have shown ways in which my own practice has been influenced by my interpretations of the material I studied. I believe that the greater our understanding of these factors then the more useful our own models and theories will become in helping us develop our role as educators and as health care professionals.