Keywords

1 Introduction

In connection with the training of nurses and other health professionals, one has traditionally relied on active learning methods, such as simulation and skills training [1,2,3]. The purpose of such learning methods is to create arenas that resemble contexts and situations involving patients that the student will encounter in his/her professional life [4]. Particularly important for this learning method is the lecturer as facilitator with pedagogical responsibility [2]. The academic staff of nursing and other health professions have normally completed professional educations. The next educational stage consists of different types of formal higher education programs (master’s degree and PhD programs), with or without a pedagogical foundation. Universities may also require documented and relevant practical and pedagogical skills (university pedagogy) in addition to the formal degree. With its emphasis on pedagogical content, a train the trainer course could subsequently represent a module that is part of a course in university pedagogy.

For lecturers who are responsible for the pedagogical and practical implementation of simulation exercises, it is important to have completed a facilitator course [7, 9]. According to Gardner, there are descriptions dating back to the 1980s of LOFT (Loft Oriented Flight Training) instructors, who relied on debriefing as a learning method [5]. The facilitator’s skills in among other things debriefing significantly impact the student’s possibilities for learning. In the words of Flatgård and Berg: “There are high demands on the competence and suitability of the facilitator, and it is crucial that there is a clear focus on systematic training, education and follow-up in this role” [6, p. 227].

Also important is the stress on standards of best practice in nursing. The skills of the facilitator are deemed to have a great impact on the learning of those taking part in a simulation exercise [7]. Further, it is crucial that organizations introduce systems that offer the facilitators the possibility of mentorship involving a senior facilitator [8, 9].

The thematic content of facilitator courses is normally not formalized in national or international steering documents [8]. However, this could vary between countries. Still, the exchange of knowledge and networking between various countries leaves an impression that there are similarities in the principles of implementation, with certain thematic and local adaptations. Usually, the courses do not yield credits from institutions of higher education. The courses tend to have a duration of 2–4 days. Among other things, they are based on pedagogical principles of adult learning, the different stages of simulation exercises, models of debriefing, the development of operationalized learning outcomes, and the role and function of the facilitator. Patient safety is a key factor. A common characteristic of such courses is the use of learning methods that require active participants [8]. This means that the participants carry out different forms of group work and take part in workshops while being able to acquire competence and skills in the role of facilitator in real simulation exercises. The competence is developed through the use of feedback and feed forward between participants and between participants and course facilitators. According to Hattie and Timperly [10], the concepts of feedback and feed forward can be described as follows:

  • Feedback → Where am I now?

  • Feed forward → Where do I go from here?

Guided by this methodology, train the trainer courses rely on the same pedagogical principles as simulation exercises. The courses are organized by different institutions and organizations, such as Stavanger Acute Medicine Foundation for Education and Research (SAFER), network-based organizations like EuSim, The Medical Training and Simulation (METS) Center, or institutions linked to the health sector like Copenhagen Academy for Medical Education and Simulation (CAMES).

2 Adult Learning and Train the Trainer Courses

Train the trainer courses are based on a variety of learning theories and theoretical perspectives on how adults learn. Adult learning is a collective category denoting an academic field that has evolved through decades and which draws inspiration from various disciplines and theoretical models. It is typically characterized by the use of the concept adult learning rather than the term adult education [11].

Generally, facilitator courses tend to emphasize perspectives on experience-based learning, reflection-on-action and reflection-in-action, the use of feed back and feed forward, as well as the significance of the socio-cultural context [3, 12,13,14,15]. By relying on learning tools that are typically used in relation to students in real simulation exercises, the facilitator will be able to become a professional facilitator of learning.

Through this approach to learning, the lecturer participating in a facilitator course will be joined by a student completing simulation exercises in a study programme [16]. The involvement of both parties will be based on the same understanding of adult learning.

Courses devoted to academic staff who wish to assume the function of facilitator are important when promoting learning among students of nursing and other health educations in general [8]. Still, only a limited number of institutions of higher education has formalized such courses for lecturers of nursing and other health sciences [11]. It has been argued that targeted courses in research method and pedagogy, like facilitator courses, are a condition for adult learning where simulation is part of the learning method [1, 6].

3 Facilitator Versus Lecturer

In higher education, the role of lecturers has over the decades developed from ensuring the transfer of information and knowledge toward a stronger emphasis on the role of a facilitator responsible for the students’ learning processes. This is evident in the more frequent use of active learning methods, like simulation, skills training, team-based learning, problem-based learning, etc. This could be considered a paradigm shift where the lecturer more than ever before assumes the role of facilitator instead of a disseminator of facts, concepts, and information [17]. The latter understanding of the lecturer’s role seems to emphasize a re-presentation of the curriculum in a study program, which is also possible for the students to access through self-studies. Even if the lecturer has articulated and disseminated the information, there is no guarantee that the student subsequently will be able to apply this information in his/her professional practice. This will obviously affect the ability to acquire action competence and preparedness in professional studies like nursing and other health sciences. A lecturer tends to have a more traditional approach to the profession, with the focus being more on the lecturer than on the learning student. The traditional lecturer has a clear-cut role or function, with a responsibility to present or share information about a given subject area or topic, as opposed to the facilitator [18].

The role of a facilitator stresses the conditions of adult learning through initiating and enabling discussion, reflection, and in-depth learning in topics or subject areas that are defined in the steering documents of the study program [17, 19]. Fundamentally, the facilitator’s role aims at promoting a methodological understanding where the student should learn to learn. It is crucial to lay the foundation for reflection, independence, and the development of skills in cooperation, communication, and responsible action [20]. These focus areas are based on theoretical perspectives on learning, such as Kolb’s learning cycle, Schøn’s concepts of reflection-on-action and reflection-in-action, Lave and Wenger’s emphasis on sociocultural context in communities of practice, as well as Dewey’s theory of experience-based learning and learning by doing [20, 21]. These perspectives are described in more detail in the introductory chapter of this book.

A facilitator could also help raise the awareness about learning as a collective process that evolves and accumulates in interaction between people [20]. According to Tøsse [21, p. 91]: “The lecturer is a facilitator who in Maslow’s words should help a person to be the best that he/she is able to become.” A facilitating professional views learning rather as dialogue than pure dissemination of knowledge [21].

This is evident in the reflection (debriefing) phase of simulation exercises, where the facilitator enters a dialogue with the students to reflect on a concrete scenario related to the learning outcomes of the relevant activity [22]. Further, it is also important that the facilitator applies his/her skills to initiate transformative learning. Transformative learning is a type of learning where the students are made aware of their own opinions and mental habits. This typically takes place when the students discover that their opinions are not necessarily consistent with what has been implemented. Generally, transformative learning happens through reflection that includes the emotional aspect of the learning process [20]. This form of learning is also described in social cognitive theory [20, 23].

A lecturer operating in the role of facilitator assists the students in their learning processes and thus helps cultivate new skills instead of assessing qualifications. Skills development in relation to adult learning appears to be something different from what is traditionally associated with development of qualifications. The term qualifications is often seen in relation to a specific position or function [24]. In higher education, the commonly applied concepts are knowledge, skills, and general competence [25]. This means that the lecturer in the role of a facilitator should pave the way for the learning of the individual student [19]. The facilitation skills of a lecturer may also help reduce the gap between theoretical and practical activities [26]. Healthcare Simulation Dictionary defines the role and function of a facilitator like this:

An individual who is involved in the implementation and/or delivery of simulation activities. For example, faculty, educators, etc. An individual that helps to bring about an outcome (such as learning, productivity, or communication) by providing indirect or unobtrusive assistance, guidance, or supervision. For example: The debriefing facilitator kept the discussion flowing smoothly. [27, p. 18].

4 The Significance of Common Language and Framework

In connection with simulation exercises, there is usually a framework underpinning the administrative and practical implementation, as well as the planning process. Administrative and practical considerations could, for instance, include selecting dates, room booking, access to adequate learning resources, etc. With regard to the planning of educational activities, important factors are scenario planning, choice of equipment, various learning tools and forms of simulation based on the learning outcomes, etc. [22].

As described earlier in this chapter, it is crucial that lecturers operating as facilitators have completed facilitation training courses [6]. It is also important that the content of the facilitator course corresponds to the standard of best practice, reflected in the International Nursing Association of Clinical Simulation and Learning’s (INACSL) Standards of Best Practice (Simulation Standard V: Facilitator):

A proficient facilitator is required to manage the complexity of all aspects of simulation. The facilitator has specific simulation education provided by forma coursework, continuing education offerings, and targeted work with an experienced mentor. [9, p. S23].

The content of the facilitation training courses determines the administrative, practical, and academic decisions on which the simulation exercises in nursing and other health education programs are based. Lecturers who assume the role of facilitator at the end of the course would have different professional backgrounds and be at different stages in their careers. A train the trainer course that is specifically designed for the facilitator role should be a comprehensive research-based and knowledge-oriented course based on the standard of best practice for professionals of nursing and other health educations. Just as the students enrolled in formal study programs, lecturers who strive to develop their skills through courses, such as the facilitator course, would require a so-called community of practice. The communities of practice could be described as follows: groups in which the participants share interests, problems, or ideas within an area and where they develop their competence through regular interaction and dialogue with each other. Communities of practice tend to be informally organized cooperative groups of learning. This does not mean that they are disorganized but rather that they are informal settings without reliance on traditional organizational control. The bond between the participants is based on their joint commitment, which in turn relies on the responsibility and effort to develop a common project. This commitment does not necessarily demand homogeneity and agreement. On the contrary, diversity is crucial in driving the cooperation forward [28]. Such a community of practice would promote learning from the course itself and the learning outcomes of the lecturers. In addition, the community will represent a counterbalance against the trend of individualization [19, 20].

Based on the different experiences among the lecturers involved in the course regarding active forms of learning, it is important to develop a learning process that takes these differences into consideration. This will affect the individual lecturer’s ability to operate as an independent facilitator after completing the train the trainer course. It could be advisable to apply a structured framework, like Dreyfus and Dreyfus’ competence steps, which take you from novice to advanced beginner, competent, proficient, and finally expert. Through these steps, the lecturer in the new role as facilitator will be able to acquire competence [21]. This model represents a learning process which offers an opportunity: “...which takes you from a rule-based and context-dependent beginner’s behaviour to an experience-based and context-independent expert behaviour” [21, p. 128].

The learning outcomes and content of the train the trainer course make it possible to develop a common language and comprehensive perspective on adult learning, which is useful for other roles and functions as well. Development and the focus on a joint language could prevent the facilitation of simulation exercises from becoming arbitrary and individualized [19]. In this way, the students will encounter facilitators who, regardless of personal characteristics, has a focus on adult learning and active learning methods like skills training and simulation.

When developing simulation exercises, it is common to apply a structured, practical form of implementation, which normally and traditionally consists of a familiarization phase (briefing), an implementation phase, and a reflection phase (debriefing) [29]. The facilitator course provides the lecturer with knowledge, skills, and general competence that should also benefit the student’s learning. The mentioned framework enables an opportunity for learning.

5 The Facilitator’s Competence: Side Effects and Synergies

The facilitation competence among lecturers of professional education could also involve some additional effects and synergies that ought to be highlighted. This could include educational leadership skills for those responsible for study programs or courses, development of new learning methods and forms of examination, support for colleagues through mentorship, and implementation of teamwork. Lecturers who have completed the train the trainer course should be in a good position to successfully implement simulation as a learning method in nursing and other health disciplines. Accordingly, the knowledge, skills, and competence of facilitation represent crucial components of educational leadership as a discipline [2]. This is relevant for lecturers with course responsibility or heads of studies, as well as advisors working with people in leadership positions. Obviously, it also applies to lecturers-turned-facilitators who use student-focused approaches and learning tools that promote learning based on a useful design reflecting the learning outcomes of the study program. One could be guided toward the learning tools required to achieve the learning outcomes of the course [18]. Lecturers with facilitation competence will be in a particularly good position to work on learning design in professional education.

The facilitation skills could also be useful when selecting forms of examination in nursing and other health disciplines. Toward the end of the study program, the student normally needs to go through a summative assessment, which is based on the requirements of society. The society needs to ensure that the individual student has acquired the necessary competence and obtain documentation in connection with admission to further studies. A lecturer with facilitator competence could in this context contribute to the development and implementation of examination forms that promote adult learning.

Examples of this are case-based written examinations or simulation-based forms of assessment. A facilitator has a stronger focus on student-centered learning than a social control system, representing a counterweight against traditional examination forms (school examinations) and a new approach toward adult learning [19].

In nursing and other health disciplines, there has been a tendency to put more emphasis on the phenomenon of teamwork, which is in line with the focus on general quality and patient safety in the health services [30]. Simulation as a learning method is well suited to develop competence and skills in teamwork [3]. As mentioned earlier, lecturers with facilitator competence could give valuable contributions to the implementation of team-based learning in different study programs. These contributions may be reflected in the steering documents of a specific course, or more generally in the study program through implementation and development of simulation exercises [31].

In higher education, there is a growing need to establish a system that enables facilitators to receive mentorship from, for instance, senior facilitators [8, 9]. By systematically applying a system of mentorship, as a form of inter-colleague support, lecturers will be able to receive feedback and feed forward, in the same way as the students. According to de Lange and Lauvås [32], colleague support is a form of supervision that involves professionals at the same educational level. In this context, a mentorship system where the facilitation skills are applied in relation to colleagues can be defined as a form of colleague support. As mentioned above, the concepts of feedback and feed forward are useful [10]. An example of this could be a situation where de-briefing takes place following a simulation exercise, where a senior facilitator has participated as an observer. The following questions and statements could be natural in a conversation between a mentor and his/her colleague:

  • What are you satisfied with?

  • This is what I think you should be satisfied with.

  • What do you think you could do differently next time?

  • This is what I think you should do differently next time.

This is a systematic, simple, and concrete structure that could enable adult learning [33]. The contribution of the senior facilitator is to combine experiences with the possibilities for transformation. This makes it possible to use facilitation skills to create positive side effects for the learning party and also discover useful synergies in the lecturer’s daily work. Feedback and feed forward ought to be seen as beneficial for all learning [33], and the significance of colleague support has already been thoroughly described in the literature [32].

The abovementioned colleague support, through a system of mentorship where facilitation skills are used, should be viewed in relation to the concept of lifelong learning. Lifelong learning may happen through both formal and informal learning and represents a form of strategy for all types of education, as well as learning in professional life and life in general. Lifelong learning is thus a natural component in the concept of adult learning [34].

The competence acquired through facilitation, among other things, is also transferable to other contexts of learning in higher education. Examples of this can be supervision of theoretical student work, conversations with students who experience challenges in their studies (advisory conversations), or formative assessment in connection with clinical practice. According to Wahlgren [35], a lecturer working in higher education should be able to assume different roles and develop skills in various contexts. A lecturer with facilitation competence ought to be able to perform such a role and use the skills that Wahlgren considers necessary for a supervisor and coach. The mentioned roles are particularly important when promoting adult learning [35]. How facilitation skills could benefit lecturers with years of professional experience has not been clearly highlighted in the literature. But one could well assume that facilitation competence represents a contribution to a more student-centered understanding of learning.

6 Conclusion

The facilitator has a key function in simulation exercises for students in nursing and other health disciplines, given his/her responsibility for enabling successful learning processes. The skills of the facilitator are therefore critically important in enabling the learning of the students. This competence is available through train the trainer courses, which are based on the principles of simulation as a learning method and rely on theoretical perspectives on adult learning.

A systematic train the trainer course could help the facilitator achieve professional confidence and a solid foundation for implementing his/her particular role. The framework, content, and learning outcomes of the facilitator course have helped create a common language and a comprehensive perspective on adult learning. This will ensure that students encounter a facilitator who relies on context-independent expert behavior instead of an arbitrary and individualized role.

Generally, the facilitator tends to rather emphasize his/her role as an active enabler of student learning than an instrumental function of conveyor of facts, concepts, and pure information. This separates a facilitator from a lecturer. Moreover, the facilitation skills among lecturers of nursing and other health disciplines could yield additional effects and synergies that are useful in their general professional lives. Facilitation skills could be applied in all types of educational leadership, in the development of learning design, and when selecting between different forms of examination. With facilitation skills, lecturers could also help cultivate competence related to teamwork. Another additional effect is the possibility of using the mentorship system of the train the trainer course, with senior facilitators providing support for colleagues at the same professional level. The roles of coach and supervisor, which are developed through the train the trainer course, may also be applied vis-à-vis students, for instance, in connection with advisory conversations or formative assessments in clinical practice.

The ability to alternate between roles in different situations and contexts is significant when promoting adult learning. The focus of the train the trainer course with regard to student activity and lifelong learning can be transferred to other learning situations. Even if the importance of facilitation skills is not strongly emphasized in the literature, it is fair to assume that this competence will help promote a more student-centered learning perspective among lecturers of nursing and other health professions.