A NTECEDENTES DEL TEMA

A second theme that emerged from the participant interviews focused on the simulation learning environment. Specifically, the ability to learn with minimal risk and reduced pressure was reiterated by all seven of the interview participants as positive aspects of the simulation environment. Zayapragassarazan et al. (2016), state that effective learning involves providing students with a sense of progress and control over their own learning. This requires creating an environment where learners have a chance to try out or test their ideas (Zayapragassarazan, et al., 2016). Moreover, the learning climate should be one that causes adults to feel accepted, respected, and supported where there is freedom of expression without fear of punishment or ridicule

(Knowles, 1980). Per Knowles (1980), the learning environment should be one that makes adults feel at ease in order to establish a positive learning environment for all learners.

According to Jones et al. (2015), simulation-based medical education can provide a safe, controlled environment where problem-based learning is developed, and competences are practiced. Furthermore, simulation can allow users at all levels, from novice to expert, to practice and develop skills with the knowledge that mistakes carry no penalties or fear of harm to patients or learners (Bradley, 2006). Four of the seven participants reported that simulation did provide them with a learning

environment that was non-stressful and gave them the opportunity to think through their clinical actions during the scenario. Participant G stated, “I think it was a good experience to recognize room for improvement, and learning opportunities, it’s always good to think about these things in a non-stressful environment as well.” Participant E said, “This was an opportunity to operationalize what you know and solidify the thought process, and differential diagnosis, in a setting where there are no

consequences.” Participant D reported, “It allows us to have a patient scenario without the added pressure of the patient there.” Participant J stated, “As a whole, the

simulations I've done over time have been very useful in terms of sort of developing comfort with acute life-threatening situations in a lower stress situation and sort of going through the steps and being then prepared to lead situations where there is an acute life-threatening situation.”

Per Gordon et al. (2001), allowing learners to live through a realistic

simulation training. Furthermore, simulation- based medical education can create conditions where making mistakes is not harmful or dangerous to patients but is, rather, a powerful learning experience for students (Ziv, Ben-David, & Ziv, 2005). Three of the seven participants reported that the simulation environment provided them the opportunity to practice clinical skills and apply theoretical knowledge with the ability to make mistakes that did not harm any patients. Participant C stated, “There’s no actual consequences to it [simulation], so I think it's just a really good way to make clinical decisions in a way where you're not actually hurting somebody with it.” Participant B reported, “It's kind of nice to be able to afford to be wrong without negative consequences in the real world, and I think that's something that is really important because we all make mistakes.” Participant H said, “There is pressure but it's not the pressure of doing something wrong and having someone lose their life.” As affirmed by Gordon et al. (2001), the simulated environment can allow trainees to “live through” an array of important medical cases without the issue of patient safety.

Another element of the simulation environment that was brought up by two participants during the interviews focused on the positive aspects of observing and learning from peers during simulation scenarios. Participant C stated, “I actually really liked working with my colleagues and seeing how they were thinking about things that I wasn't necessarily thinking about and being able to go back and reflect on what they said.” Participant B also stated, “You get to see how other people approach the problem and what do they focus on and you know you learn from each other. It's like role modeling essentially.” Nestel and Kidd (2003), state that student-led groups often work together to achieve set goals by exchanging ideas and experiences of related

knowledge, attitudes, and skills. Furthermore, the quality of human interaction among health professionals is an essential element in optimal delivery of healthcare (Ziv et al., 2005).

Per Ziv et al. (2005), a pivotal feature of simulation-based medical education is that it can provide medical students and professionals with an opportunity to learn through their own mistakes. Moreover, the simulated learning environment can allow learning and re-learning as often as required to correct mistakes, allowing the trainee to fine-tune skills to optimize clinical outcomes (Lateef, 2010). A summary of the seven interview participant responses found that a positive simulation experience was one that cultivated a low-risk, minimal-pressure environment. In addition, an optimal simulation environment allowed trainees to make mistakes and think through

scenarios to refine their theoretical knowledge and practice their clinical skills. Currently, the challenge of simulation-based medical education for many programs is to simulate an authentic healthcare environment that will enable trainees to immerse themselves into the simulated scenarios as a real scenario, and to maximize the learning from the simulation (Ziv et al., 2005). As stated by the cardiology program director, “It takes time and often many resources to create a meaningful simulation, and one that will cultivate a positive learning environment for trainees” (Program Director, personal communication, January 14, 2018).