Keywords

1 Introduction

The purpose of this book is to present the evolutions of the research field about simulation-based training and the development of various methods to analyze these educational programs as they are today widely used in many professional areas. It contributes to a reflection for innovative training design principles and is meant for professionals involved in pedagogical design or in a reflection upon simulation -based practices. The works gathered in this book, and this chapter is no exception, are mostly related to the activity analysis’s point of view and more specifically the French-speaking ergonomic approach which the English-speaking audience is perhaps less familiar with.

This particular chapter aims to contribute to a global reflection on the relationships between theoretical frameworks and design principles by analyzing the links between how learning is conceptualized and how simulation-based training programs are implemented (Dennick, 2016). For research programs in education, learning theories circumscribe the phenomena that are examined. Learning theories have a substantial impact on methods, data analysis, and interpretations of the results. We believe that the same goes for the design of training sessions in adult education, especially for simulation-based training that often articulates several learning methods in complex training environments.

The situated cognition approachesFootnote 1 are strongly linked to simulation-based training by definition. We would like to take a look at the theoretical roots of these approaches and question their translation to design principles for simulation-based training sessions. Our goal is to go beyond the design principles that are frequently used in the literature about simulation-based training and contribute to their actualization.

We believe that a strong point of view about how learning occurs, in addition to a precise knowledge of theoretical frameworks in adult education, can provide some advantages in design and clarity about learning objectives, goals, and methods to achieve it. Therefore, it can be a useful tool for professionals dealing with training design sessions.

1.1 Multiple Practices in a Changing Context

Simulation-based training has been integrated into medical and nursing programs in both vocational education and continuing education for several years now by training policies in medical education. The spread of these methods and the expansion of practices have opened up various themes and areas of development, such as training in interprofessional collaboration (Peeters et al., 2017) for technical and nontechnical skills or the investigation upon the notion of professionalism (Birden et al., 2013; Bracq et al., 2019; Yucel et al., 2020), role model (Johnson et al., 2012), or deliberate practice (Ju et al., 2019).

These methods are now being challenged by the growing development of distancial training programs and digital learning methods such as serious games, online content, and collaborative work platforms, which are permanently modifying the relationship between professionals and training . Until recently, professional training has been dominated by so-called face-to-face training programs, delimited by a so-called synchronous framework. It has been well reported that simulation-based training is particularly costly in terms of time and resources (Walsh & Jaye, 2012); (Maloney & Haines, 2016). The cost–benefit ratio of the implementation of these training programs is today strongly questioned by multiple digital devices such as smartphones, laptops, or tactile tablets.

This trend is part of a general development of new training technologies that offers ready-to-use devices more or less adaptable to the professional problems. The role of those in charge of training and development management is therefore currently to manage adequacy between the current offers and the “in-house” design of training according to the needs of the field. We think that this reflection and these choices can be nurtured by a detailed knowledge of learning theories and their implications in terms of training program design (identification of goal situations, which professions are involved, etc.). Simulation in health care has now been practiced for several decades and is in the process of losing its hegemony. This implies a tightening of the understanding of the learning phenomena at work to make it more relevant and effective in a global context of reduced resources in order to make good use of the plasticity of this type of device.

1.2 The Various Approaches of Situated Cognition

The situated cognition approaches postulate that learning is context-related. It is in part on this postulate that current simulation training programs are based. By reproducing the ecological context or area of a work environment in a secure setting, those training programs have put in their center the relationship skill’s acquisition (technical, clinical, or teamwork) and the professional context (Kneebone, 2005, 2010; Østergaard et al., 2011). These programs aim to develop and enhance learning for a vast number of professional areas, especially healthcare professions. By focusing on the concrete aspects of a professional situation—reproducing a specific dynamic, recreating parts or the whole of a work environment—simulated training allows the learner to build strong contextual knowledge that can be further analyzed, which will enable them to validate or invalidate the efficient and inefficient aspects of their work routine. Even though the format of such simulated training can vary considerably from one to another depending on the goal (part task trainers, high fidelity simulators, crisis scenario , basic and usual task training ), the situated cognition premise is, by nature, at the root of any simulation-based training .

First of all, it should be mentioned that this stream of research is not a unified theory unit but includes several currents that are not always unified, which makes it complex to refer to a single paradigm or a specific theory. Numerous disciplines such as linguistics, psychology, and ergonomics each have different notions, notably notions of situation and different focuses toward the objects of study. Footnote 2

1.3 Plan of the Chapter

Of course there is also a multiplicity of practices and work areas that are using simulation. We will deliberately stay at a very general level. Simulation for learning purposes is an extremely broad field. The challenge is not to focus exclusively on one type of program while remaining precise enough to provide the reader with relevant information. We will focus on face-to-face programs involving one or several learners and one or several instructors accompanying the session by piloting or not the simulator and followed or not by didactic sequences of debriefing or mixed type.

In the rest of this chapter, we will try to synthesize the main topics of the approaches to situated and embodied cognition: its origins and the main trends and disciplines where the topics about cognition, learning, the body, and its environment are central. We will also refer to research work that falls within this approach. We will then make the link with a brief review of the literature on simulation in the medical field and its links with situated cognition. The objective of this part will be to show what conceptual links tie simulation training programs and this stream. Finally, we would like to suggest design principles and examples that have emerged from the different chapters of this book and can be useful to rethink simulation-based training with a “situated approach’s point of view.”

In order to carry out the literature review of point 3, we have focused on the main publications dealing with situated cognition in the field of simulation -based training by prioritizing articles exposing the theoretical foundations of these programs and recent publications (<10 years) (keywords “Situated cognition“; “simulation based training“; “incarnated cognition”; “embodied cognition”; “experiential learning”).

2 Situated and Embodied Cognition: What Specificities for Learning?

As mentioned before, it would be difficult to track the evolution of the situated cognition field as having a single trajectory or a steady given number of scientific disciplines. This group of theories brings together a multiplicity of research fields, programs, and convergent hypotheses from various disciplines (anthropology, sociology, cognitive sciences, psychology, etc.) whose dialogue is particularly fruitful for the development of pedagogical design. We deliberately choose this chapter to address the group of research, which seems to bring a certain number of elements of understanding and promises of development for training design. Well aware that this selection is necessarily reductive and influenced by the approach in which we conduct our researches and professional activities (an ergonomic approach to training based on the postulate of enaction), our goal is to bring a view that we hope will help to give a voice to other theoretical aspects than those generally called for in medical education research.

The main idea that unites these approaches is that cognition is linked to the characteristics of an actor and his environment in permanent co-construction according to the statuses and variations of these two “poles.” These approaches, which focus their research on the situation’s characteristics, or psychological, social, cultural processes, are opposed to the idea that cognition results from a selection of stimuli that are perceived by the perceptual system in a given environment, thus making learning as an information processing system.

We can gather four different themes that are enlightened by the research from these approaches: (a) an individual/action and situation conception that cannot be dissociated; (b) the role of experience in cognition; (c) embodied cognition; and (d) cognition and culture.

2.1 Individual/Action and Environment

The beginning of the cognition stream is generally identified with the work of Lucy Suchman (1987, 1993), who showed the distributed and opportunistic nature of learning in relation to the dominant paradigm in cognitive psychology that has been cognitivism, where learning is primarily a symbolic and individual internal process (Paige & Daley, 2009). Research from the cognitivist paradigm conceptualizes learning as a symbolic information processing system such as computers: selecting stimuli from the situation that are relevant to the action to be taken. Lucy Suchman’s work (Theureau, 2004b) has highlighted a new way of conceptualizing the notion of situation (resulting from a “bundle of hypotheses” already put forward a few years earlier in response to the paradigm of cognition as an information processing system, as explained in Theureau (2004b), and more specifically the stream of cognitive anthropology (Corcuff, 2008; Hutchins, 1995) and a new reading of Vygotsky’s psychological work. In summary: “cognition is not located in the head, but in an in-between, between the actor and the situation, to which the other actors belong. Consequently, on the one hand, the relevant cognitive phenomena mainly concerns perception and action, and on the other hand, the essential place of their study is the work situation itself, because if one tries to study them by moving from a work situation to a laboratory situation, one risks losing them allFootnote 3” (Theureau, 2004b, p. 7). Cognition is therefore not conceptualized as having elements existing outside the actor but is inseparable from his interaction with the world.

Hutchins’ work develops the notion of distributed cognition. His famous study on aircraft piloting simulators (Hutchins, 1995) highlights the statement that “cognition is distributed between actors and material supports that together constitute a ‘system of distributed cognition’ (or ‘cognitive ecology unit’)” (Theureau, 2019). In other words, cognitive processes are inseparable from the material but also sociocultural environment in which they are deployed. Studying or being interested in cognitive processes thus implies understanding and a unit of analysis including an individual/action/environment system.

It is the dynamic that the actor maintains in a work situation mediated by his activity (a “situation” must be understood as the set of constraints that influences the actor’s action) that is the subject of researches resulting from the French-speaking ergonomic approach (Ombredane & Faverge, 1955). This research field aims to improve human relations to work. The notion of activity is crucial here because it is the product of (a) the state of the subject (the individual known as the actor), (b) the situation in which it takes place, and (c) whose results lead back to changes in the actor and the situation. The action then becomes the revealer of the cognitive processes underlying the interpretation of a situation by an actor in (a) a specific state, (b) with a given intention, and (c) provides anchors for the future action’s development.

An action is therefore the result of a form of a situation’s interpretation by an actor and is concomitant with the sensorimotor processes.

Research in professional didactics (Pastré, 2011; Pastré et al., 2006) has strongly contributed to the development of professional training programs based on activity analysis and cognitive processes resulting from the relationship of the actor to the situation. To sum up, the activity is organized by a certain number of pragmatic concepts that allow the professional to both diagnose the state of the situation, to understand what is happening, and to act on its progress in an efficient way: These concepts are never evoked as such by professionals but inhabit formal and informal exchanges. The main idea of professional didactics has been to identify these concepts in the activity (see the work of Pastré on the activity of injection molding machines) (Pastré et al., 2009) and to transpose them (in the manner of the didactics of disciplines in teaching) to professional training. These trainings are therefore based on the real activity of the operators and the pragmatic concepts relating to class situations useful for a given professional field.

2.2 The Role of Experience

If the hypothesis of the activity as it is described in particular by French-speaking ergonomic research is taken seriously, then the actor’s activity produces an immediate experience (as in “to experiment”), which aggregates and organizes the actor’s future knowledge (as in the expression: “having experience” ). Experiential learning carried out by researchers such as Kolb (1984) and Schön (1983) focuses on how concrete experience is transformed into a more general and abstract experience that can be mobilized in a wide variety of situations.

For Kolb (1984), learning proceeds from concrete experimentation by the actor, followed by a reflexive process that feeds into the construction of abstractions that are then explored in new concrete experiments. This verification leads to new hypotheses, new questions, thus leading to a new cycle. This learning cycle shows the importance for Kolb of the relationship between the three factors involved in this process: the experience as subjectively lived by the actor in singular situations (he experiences and takes part in an experience ), the understanding of this situation, and the construction of knowledge from this context. Kolb has also developed a classification of “learner” styles characterized by the pre-eminence of one or the other of these stages of the cycle (Kolb, 1999). Simulation-based training is generally designed according to an alternation of three phases (simulated briefing–scenario–debriefing ). It is mainly oriented toward a reflexive approach to learning, which is characterized by the importance given to the debriefing phase compared to the realization of the simulated scenario (Horcik, 2014).

The notion of experience is also mobilized in research on the embodied dimension of cognition, which is part of a phenomenological perspective of action in that it can only be known through the actor’s point of view (Sartre, 1956) (Merleau-Ponty, 1962) and more particularly on the paradigm of enaction.

2.3 Embodied Cognition

Embodied cognition is centered on the relationship between cognition and its “embodied” dimension (Shapiro, 2014). It emerged in the 1990s initiated by Varela Thompson and Rosch (F. Varela et al., 1991) and then Maturana and Varela (1992).

The research stream is based on the postulate of autopoiesis developed by Maturana and Varela (Maturana & Varela, 1992) and Varela, Thompson, and Rosch (1991). This paradigm postulates cognition as the result of autopoiesis: the property of a living system to produce itself despite disturbances and from disturbances. These disturbances may come from the environment but also from the system itself. The dynamics of the interactions between the system (called actor) and its environment is called structural coupling. This coupling is said to be asymmetrical insofar as it is the structure of the actor that selects the disturbances of the environment impacting its own organization. Understanding the history of coupling (the interactions between the actor and the environment) is therefore a matter of cognition.

Cognition is constantly accompanying action: as making a world relevant for an action to emerge or enact a world also known as the “own world.” The notion of own world does not correspond to an objective world “already there” to which the coupling adapts but corresponds to a set of disturbances relevant for the actor at a given moment. Coupling is, for example, determined not only by the sensory-motor capacities of the system but also by its concerns or intentions (such as concerns related to nutrition or protection). The actor’s world is thus inseparably linked to the action. In this paradigm, acting is equivalent to knowing, thus expressing knowledge already assimilated and under construction. Cognition does not therefore result from an adaptive intention of the system but from an essential and inherent dynamic of life: “By using the term embodied we mean to highlight two points: first, that cognition depends upon the kinds of experience that come from having a body with various sensorimotor capacities, and second, that these individual sensorimotor capacities are themselves embedded in a more encompassing biological, psychological and cultural context” (Varela et al., 1999, pp. 172–173).

The notion of “own world” is close to the notion of Umwelt by Von Uexküll (1965), who in the framework of his research in biology put forward the hypothesis that each living species has its own world, which is simultaneously defined by its perceptive capacities and the elements determining its survival from its environment.

To take into account the coupling for the study of human activity means to analyze the actor’s own world and to simultaneously consider cognition, action, and environment as indissociable elements of a dynamic.

According to Maturana and Varela (1992), the surface effect of the dynamics of the structural coupling of an actor and his environment could be the subject of a symbolic description admissible in the framework of the human sciences. This surface effect is associated by Theureau (2004a, 2006) with the concept of pre-reflective consciousness developed by Sartre (1956) that allows one to build a methodology to access this surface effect in professional situations.

Let us also mention Lakoff and Johnson (Lakoff & Johnson, 1980; Lakoff, 2012) and their work in cognitive linguistics that highlight the crucial role of our human, physical condition in the construction of language metaphors that shape our relationship with knowledge. Positive elements, happiness and unhappiness, the relationship with time, and cause and effect relationships are conceptualized by means of sensory metaphors (time through movement, happiness through a vertical station) derived from our sensory experience. Locating these metaphors is particularly interesting for understanding cognition and how the actor conceptualizes the world.

2.4 Cognition and Culture

As we have seen, the principles resulting from situated cognition give primacy to the point of view of the system constituted by the interactions of the actor with his environment. However, as we have mentioned, this environment/situation is made up of a given cultural anchoring resulting from a common history, shared practices that influence the action, perception, and cognitive processes of the actor (Theureau, 2004a). It is the actor’s participation in these social practices (professional or not) that will shape the understanding of the situations. A fundamental notion of this current is the notion of community of practice.

This notion developed by Lave et Wenger (Lave & Wenger, 1991) concerns the positioning of the actor who is inserted in a context defined with its rules, principles, and specific roles and fields of action that are attributed to him/her in the framework of his/her activity.

This theory highlights the existing dynamics between newcomers (beginners, or people integrating teams) and old-timers (experts, people already integrated in the socio-professional context) working together on a certain number of common tasks. To summarize briefly, beginners integrating a new activity are first entrusted with a series of peripheral tasks that do not correspond to the core activity. Gradually, as they become part of the team, they are given tasks of increasing importance in the form of coaching supervised by an old-timer until they become professionals themselves, recognized by their community and independent, thus developing an identity specific to the community.

This theory corresponds to the apprenticeship systems used in traditional training courses where a master trains an apprentice, but the vocational and continuing training systems have also developed principles derived from community of practice, in particular the notion of the role model, and the identification processes of experts in the field, but also in the creation of groups of students to reinforce the students’ sense of belonging to a company, a profession, or a social role. This notion is nowadays exploited in project management insofar as the development of means of communication facilitates the pooling of different actors that have common practices.

For training design, this means that the actor’s relationship with the world is constantly creating meanings that can be partially shared. The preliminary study of the activity, which consists of the actor’s relationship with the world, the meaning he gives to his action, and his perception of the world in which he participates, using observation and interview methods, allows the modeling of work situations and the possibility to design training courses focused on the key aspects of the targeted activity (Flandin & Ria, 2014; Olry & Vidal-Gomel, 2011; Ria & Leblanc, 2011). Research in French-speaking ergonomics also mentions that the analysis of the training activity is also a source of development and learning (Durand, 2008).

In actual practices of simulation-based training design in the medical field, these dimensions seem relatively absent to us insofar as the situations serving as a basis for the scenarios seem to take little account of the actors’ point of view and the construction of their activity. In the following section, we will detail the points that we believe are crucial to address in order to take into account the principles of cognition in simulation .

3 Three Missed Appointments Between Medical Simulation and Situated Cognition

We identify three major focus points for the development of simulation-based training session on taking the paradigm of situated cognition as a design guide. The first one concerns the building of scenarios based on situations and real practices. The second concerns the relationship with the learning situation as a provider of affordances, anchors relevant to the participant (Durning & Artino, 2011). The third theme is the transfer of knowledge acquired within a group (a community of practice) to an individual and from the individual to his or her daily practice (Paige & Daley, 2009). In this part, we are talking about three missed appointments insofar because, after studying the recent literature, three major references to the current state of situated cognition structure the conceptualization of simulation-based training programs: (a) building scenarios from situations and practices; (b) the bodily dimension of learning; and (c) the primacy of the participant’s sense of action.

We believe that some of the elements mentioned in the previous section may allow for an extension of the design principles in simulation-based training or may reorient some design strategies. After a brief summary of the state of the literature on the three topics, we will successively make some conceptual propositions in order to show a broader side of the situated cognition approach for training design.

3.1 Building Scenarios from Situations and Practices

Training programs using simulation focus on specific occupations and scenarios centered on particular professions. The interdisciplinary simulation trends that are currently undergoing strong development are also based on the notion of community of practice in the sense that the scenarios seek to integrate the cultural and socio-professional context of the targeted activity, thus questioning the functional link between the different professional fields. The objective is to foster cohesion between the different members of the same profession. Reflection and exchanges are promoted and facilitated by the trainer (Onda, 2012).

3.1.1 Taking into Account Simulation as a Cultural Practice

One of the difficulties of the concept of community of practice applied to training design is that the place of “cultural” practices in the design is today dominated by the vocabulary of training policies and human resources policies obliterating real practices in the field. The problem is therefore in the constitutions of curricula, which are today in medicine mainly based on “evidence-based” research, incident reports, or emblematic cases. This raises questions about the purpose of training systems in medical institutions. Should they adapt to field practices (or adapt existing practices that can be improved) or follow the principles of harmonization of training systems induced by the globalized research trends currently at work in medical education research and development?

A crucial point raised by the work of Dieckmann et al. (2007) is that the simulator and more broadly simulation-based training constitute specific social practices with their own codes that must also be integrated by the learners. Dieckmann et al. (2007) submit an analysis of simulation programs using Goffmann’s framework theory of experience (Goffmann, 1974) and show that these cultural practices and norms play a very important role in the design of simulation training either as constraining the activity of the trainers or as having a poorly evaluated impact on the activity of the participants during the simulated sequences and thus potentially on the learning that takes place there.

Mc Niesh (2015) also shows that the simulated scenarios are the subject of constant negotiation between the trainers, producing a scenario and implementing a certain number of instructions, and the activity of the students constantly “altering” or challenging these elements individually and collectively. These include familiarization of the context by the students, simulating the role of an experienced nurse (the study focuses on nurses in training ), learning to work by making mistakes within the simulator, practicing an activity while being observed and evaluated, learning to consider the dummy as a real patient in order to perform an adequate activity in simulation , and learning collectively and anticipating the debriefing . These different elements allow us to re-evaluate the notion that simulated scenarios are a mirror of the targeted professional activity.

The right balance is thus to be requested by the designers of this type of program. What is the importance given to individual learning vs. group learning vs. learning about the standards of the profession? To what extent do training systems tolerate the presence of practices that sometimes deviate from the norm that originate in the field? We believe that “practical” and “cultural” learning is mainly taught in the field on a day-to-day basis and that the challenge of simulation-based training is to determine the status of daily practice and its sometimes marginal practices in teaching. To this, cultural dimension of learning is added the concept of simulation as a social practice, which is not explicitly addressed in terms of design (Glavin, 2009).

3.1.2 Developing Non-curricular Training Programs

One of our suggestions follows Flandin’s (in this book), which is that simulation-based training in the medical field could add risk management models to their design principles. Of course, simulation in health care has a long practice of training for risk situations, especially with the development of training content related to CRM (Gross et al., 2019), but this particular method is based on a curriculum that includes safety training , but also communication techniques and situation awareness. We think that this type of training could also benefit from approaches that do not directly use curriculum-based design principles.

De Bisschop and Leblanc in this book mention the three modalities for training, namely transmissive, training , and developmental. We believe that developmental training opens up the prospect of non-curricular type training (i.e., not referring to a precise pedagogical content but rather to a type of situations). Our previous work on the training of novice nurse anesthetists consisted in maintaining the anesthesia procedure in a critical situation (incidental situation) (Horcik et al., 2014). As such, we believe that many simulator-based training courses in the medical field do not specifically make this distinction and combine curricular content (derived from evidence-based research guidelines) and developmental training aimed at maintaining an activity in a variety of situations. This type of training seems interesting insofar as it allows focusing the design more on situations and their characteristics rather than on a content of knowledge or procedures to master. They are halfway between training of the transmissive type and training of the training type and allow nuancing the mastery of these situations (constitution of knowledge on situations given by novices, for example, has regular training of skills by more expert participants). Van Daele in this book mentions the idea that a good balance between interpersonal trust between the participants allows flexibility in reacting to the hazards of the situation and distrust/vigilance/maintenance of safe procedures, which are of course essential in risk areas.

Flandin in this book also proposes four axes, which can lead to simulation-based design principles: “enactment/reenactment,” “curriculum/discovery,” “disturbance/reassurance,” and “trust/distrust.” If these four dimensions are taken into account in the training design, they then allow to work on the notion of situation while taking into account the notion of experience . Boccara, Delmas, and Darses in this book specify the notion of situation and present a method for designing scenarios based on the analysis of work situations. This proposal complements the construction of scenarios based on typical skills or procedures.

Schot, Flandin, and Goudeaux (2019) have designed a training program on a non-curricular approach based on the principle of disruption. By creating trainings that shock, or disrupt the actor’s activity, it is hoped that the latter will modify his understanding in order to restore a state of equilibrium. Once again, the phases of indeterminacy of the actor’s activity are hoped to bring about development.

If the culturally anchored dimension of the activity and the primacy of the meaning allocated by the actor to his activity are taken seriously in simulation-based design, it seems essential to us to think about the developmental potential of the situations and the activity itself. The dynamic dimension of knowledge building allows strong exploitation of the trainee’s experience as long as the trainers are familiar with the specific interview and questioning methods and the participants are also familiar with the expression of their activity (see Becceril and Ortega in this book on concomitant verbalizations). We believe that training based on this experience without a prior curriculum could be a powerful lever for professional development in the health professions.

3.2 Relationship with the Learning Situation

3.2.1 Bodily Dimension of Learning and Sensitive Experience

The literature on simulation-based training mentions the importance of the bodily dimension of learning. This is also frequently related to the dimensions of situated learning as integrating the whole body as a means of cognition. Simulation-based training that emphasizes the active participation of learners is therefore based on this principle. However, to our knowledge this dimension is not translated as design principles for simulation -based training . The fundamental principle of simulation-based training programs is the proximity of activity and experience of situations with reality, but the dimension of the body as mediating learning is little explored.

Surgical training has traditionally developed part task trainers, focused on a specific procedure to be mastered by the trainees. These simulation training techniques have also profoundly modified the way surgery training is delivered (Okuda et al., 2009).

Pediatrics also makes a wide use of standardized patients for the work of confrontations with families. This discipline also uses simulation to test the development of guidelines in relation to neonatal resuscitation. The importance of authentic activities and situations/tools is therefore a founding principle of the design (Okuda et al., 2009).

Kneebone’s work (Kneebone, 2016, 2020; Kneebone & Woods, 2014) after focusing on the development of simulators for surgical teams focuses on the “sensitive” “unteachable” dimension of surgical learning. It also uses the practice of surgery to explore the links with different professions whether they are direct (tailor, dressmaker) or indirect such as the performance of an activity under stress (restaurant services, musicians, etc.). This work focuses on analogies between various professional practices and surgery. This research postulates the transferability of skills through the identification of similar skills, allowing a step aside. It should also be noted that other of his research also focuses on the question of points of view, in particular the documentation of the practices of experienced surgeons who are now retired and who practice old procedures on a simulator with young surgeons in training to encourage verbalization. Beyond the objectives pursued by this work, it is very interesting insofar as it voluntarily and stereotypically brings into play the communities of practice and the links between old-timers and newcomers whose relationships are mediated by an old practice that sheds light on the current progress of the discipline.

According to Onda (2012), much research on simulation focuses on the evaluation of training and its effectiveness on the attitude and perception of students rather than on an actual measurement of skill acquisition. For nursing, the links between body-related skill acquisition and simulation-based training programs are not yet clear.

3.2.2 Mimetic Experience

Research on experience, and particularly research on embodied cognition, has also shown that some learning is linked to a metaphorical dimension (Lakoff & Johnson, 1980). Kneebone’s work that we have already cited above focuses on this question. What are the occupations, the activities that may be related to the surgical activity and how these apprenticeships are carried out? What can these different environments teach to the learning of surgery? This lever is powerful because it opens up to other types of environments and goes beyond the notion of goal situation. In short, it allows for innovation. As an example, let us mention the research that aimed to produce a tissue simulator, produced by a lacemaker for surgery (R. Kneebone et al., 2019). This metaphor of human tissues and textiles allows a new and low-cost exploration of the delicacy of the gestures to be performed to suture two pieces of tissue without breaking and tearing them.

We mentioned that simulation training is based on the actor’s experience and the construction of meaning. Our research has shown the specificity of the experience during simulation-based training sessions as being complex and constantly oscillating between commitments oriented toward the training program (“what do the trainers expect from me?”) and the target activity (“what do I have to do to solve the situation?”). We refer to this specific experience as “mimetic” as it is not the same experience than the goal activity it mimics. As a result, part of the design is somehow beyond the control of the designing trainer as he cannot influence the totality of this experience . By taking seriously, the complexity of this experience and its elusive aspect would allow a refocusing of the scenarios questioning trainers and tracking of knowledge construction processes (Horcik, 2014). This also raises the question of training the trainers to identify and verbalize the participants’ experience .

Another point raised by the research of Harder et al. (2013) shows that there is an interest in simulation-based training that is frequently explored, which is the role change between different medical professions. It shows that these role changes are not sufficiently thought out and scripted to have a real impact on learning. However, we believe that this shift can also promote mimetic experience and the relationship with one’s own profession.

3.3 Skills Transfer

The issue of learning transfer is linked to the ability of learners to reuse the training content in their workplace. Numerous studies have focused on this issue, and simulation-based training is a tool that is particularly well suited to the transfer of complex situations through training or the development of potentially fruitful anchors for work in real-life situations. This question is strongly linked to the topic of meaning that is given to the actor in his action and his understanding of the context.

3.3.1 Primacy of Actor’s Meaning

Research on situated cognition and simulation emphasizes the fact that the learner uses the context available to him according to his experience and his interpretation of the situation to act efficiently. Simulated scenarios as they are widely used today are based on the strong principle that they feed the debriefing in order to enhance learner’s awareness by means of a reflective debriefing , which allows coupling reflection on action with reflection in action and guides this process of creating meaning: Within the setting of simulation , perhaps the most obvious form of reflection is reflection on action. This typically occurs via a debriefing process after the conclusion of the scenario . Debriefing is a “period of self-reflection about what just took place. The overall purpose is to uncover the cognitive frame that was operating during the experience and make sense of external stimuli through internal cognitive frames” (Kuiper et al., 2008, p. 2). Ideally, reflective discussions revolve around the issues of the way in which clinical problems were identified and solved and the effectiveness of attempted interventions. This process allows for the formation of abstractions and, it is hoped, leads to the development of self-correcting practice habits when faculty can help students recognize and resolve clinical and behavioral dilemmas that occurred during the simulation (Horcik et al., 2014; Onda, 2012; Rudolph et al., 2006). Our research’s results showed that the reflexive aspects during debriefings are often overused comparatively to the simulated situations the trainees were put in, creating a gap between the lived experience in the simulator and the debriefing . This often leads to leaving the scenario as background noise, reducing the simulation to any other theoretical lesson. This leads, through a progressive drift effect, emptying of meaning of certain sequences of a pedagogical program or, in any case, not to question them in terms of the objectives pursued (Horcik et al., 2014).

A second problematic aspect would be to deprive designers of potential future orientations and developments for the design of training courses that could be partly creatively based on principles derived from learning theories. If this principle of primacy of the learner’s point of view is taken seriously in the design, it is at the heart of training for beginners, which is intended to train their interpretation of contexts and actions by making them intelligible. This is the object of the work of the current professional didactics (Pastré, 2011) and of the work of Ria et al. (Flandin & Ria, 2014; Ria & Leblanc, 2011). In the literature on medical education, the importance of mentors is paramount insofar as they make sure that the requirements of professional practices and mastery of standards are met. As we mentioned before, it is interesting to note that there is research that allows participants to explore roles other than their own at the time of training by playing the role of other professionals. This has shown mixed results (Harder et al., 2013). This aspect is used more often to occupy participants who are not the “primary” roles targeted by the training . Harder especially insists on the fact that this element could be potentiated if the scenarios strongly include work on these roles in truly interprofessional systems.

Durning and Artino (2011) mention that situated cognition theories allow training designers to think of content as more than just training . The role of the designer/trainer must therefore take into account and organize the teaching according to the environment from the perspective of the learners in addition to the content of the course. These questions show that teaching in medical education is still struggling to fully grasp the environment as fully affordant (Billett, 2010). Traditionally, the part between “teaching” and facilitation with students is determined according to their level. The more experienced professionals the participants are, the less teaching part is required and the more facilitation part is important (Rudolph et al., 2007). Durning and Artino (2011) reintroduce a planning aspect into the trainer’s role as facilitator, also informing this notion of role model or expert often referred to in the medical literature.

It is also interesting to note that there is a great temptation for the designer/trainer to start piloting situations rather than the training sessions themselves. Simulation-based training allows many possibilities for trainers to modulate the learning context. But in doing so, is it possible that the main focus of these sessions slowly drifted from a focalization on learning to a focus on the situation itself?

“The teacher should not only spend time on drafting discussion points for the session, he should consider, for example, learner perspectives and preparation, potential group dynamics, tools available in the teaching environment (artifacts) to assist the learner and how to best optimize them, and authenticity of the instructional format (how close to actual practice are the materials). Situativity theory would argue that it all matters and though the instructional designer cannot control how the different factors interact, explicitly paying attention to (and adjusting, as much as is possible for the teacher) the components of the factors and their interactions can optimize learning. This model also provides a scaffold for changing instruction by encouraging teachers to focus on not only the content, but also on these other factors and how they play out in the session.” (Durning & Artino, 2011, p. 196).

Working with the trainees’ experience as a fundamental principle of scenario design therefore partly helps to move away from the idea that reflexive learning is the only way to make trainees learn. By analyzing situations beforehand in terms of the actors’ perception of their situation and activity (whether novice or not) and consciously transposing them into a simulated scenario , it seems easier to confront experience and activity from different points of view and expertise and thus promote their transfer.

3.3.2 Toward a Positive Conception of Risk and Doubt

One of the key aspects of simulation training is learning procedures or ways of acting in common or degraded situations. The hoped-for challenge here is to learn ways to manage the crisis in a real situation. Simulation-based training frequently mentions the characteristic of these trainings to constitute a “protected space” where the error can be fully experienced. Our research as well as that of other authors qualifies these assertions insofar as they have shown that the experience of participants in these trainings is complex and oriented toward an expectation of problematic elements (Dieckmann et al., 2007; Horcik et al., 2014). Moreover, the collective and artificial dimension of this environment makes the experiences of error particularly salient despite the efforts of trainers to make these experiences constructive.

The work of De Bisshop and Leblanc in this book shows training for leaders in the high-intensity military environment, in an environment where participants are forced to organize their activity to deal with the different eventualities threatening their integrity and that of their group. One of the key points of this research is that risk is here thought as a component of action and not as an object to be avoided or controlled exogenously. This seems to us to be a complete break with simulation training in the medical field where risk is essentially addressed to be controlled by means of procedures and cases resulting from evidence-based research. By designing high-intensity training courses based on the disruption of the trainees’ activity and exploiting the doubt or wanderings of the participants as a learning vector (see Flandin and Bombeke in this book) for the medical field, we believe that this could open up the development of attentional and reactive capacities in the event of a crisis .

It can be assumed that the practices initiated with the development of simulation-based training are not simply pedagogical and theoretical quarrels “off the ground.” They are part of research and the development of programs in tension with related training methods and programs, training policies, and hospital management. Thus, it can be assumed that the assimilation of new safety standards has somehow taken precedence over the exploratory aspect of professional practices via simulation and a real turning point in the way of thinking about professional practices in the medical field.

4 Conclusion

We believe that a large part of the systems currently deployed in training institutions are partly based on these presuppositions, but in a more or less conscious way. What we are trying to argue is that a conscious endorsement of these principles by designers–trainers may open up to a clarification of the design steps. As Flandin mentions in this book, the relationship between analysis and design may need to be rethought in a more detailed way concerning simulation-based training. Is the analysis at the level of the work situation, the learner’s activity within the simulation , or the conduct of the simulation ? A fine analysis of the reference activity as described in the other chapters of this book can allow for the precision of the contents and to take into account the sociocultural aspects of the activity in which the actors are involved, their level of mastery of the activity, and to work on the design of scenarios.

We also think it is important to take into account that training programs including simulation training are nowadays governed by training policies and academic circles. In this sense, we realize that these design changes in the daily activity can be a source of difficulty in challenging traditional design principles such as the idea of a non-competitive design of training or to promote the experience of the trainees without the transmission of previously established procedures.

This chapter invites us to consider the design of simulation training in the medical field in the light of theories from the field of situated cognition. This imprecise and biased account is intended more as an appeal to consider these theories as the foundations of the design of simulation training programs than as an exhaustive review of theory and literature.