Healthcare problems are complex; they exhibit both detail and dynamic complexity. It has been argued that Discrete Event Simulation (DES), with its ability to capture detail, is ideal for problems exhibiting this type of complexity. On the other hand, System Dynamics (SD) with its focus on feedback and nonlinear relationships lends itself naturally to comprehend dynamic complexity. Although these modelling paradigms provide valuable insights, neither of them are proficient in capturing both detail and dynamic complexity to the same extent. It has been argued in literature that a hybrid approach, wherein SD and DES are integrated symbiotically, will provide more realistic picture of complex systems with fewer assumptions and less complexity. In spite of wide recognition of healthcare as a complex multi- dimensional system, there has not been any reported study which utilises hybrid simulation. This could be attributed to the fact that due to fundamental differences, the mixing of methodologies is quite challenging. In order to overcome these challenges a generic theoretical framework for hybrid simulation is required. However, there is presently no such generic framework which provides guidance about integration of SD and DES to form hybrid models. This research has attempted to provide such a framework for hybrid simulation which can be utilised in healthcare domain. On the basis of knowledge induced from literature, three requirements for the generic framework have been established. It is argued that the framework for hybrid simulation should be able to provide answers to Why (why hybrid simulation is required), What (what information is exchanged between SD and DES models) and How (how SD and DES models are going to interact with each other over the time to exchange information) within the context of implementation of hybrid simulation to different problem scenarios. In order to meet these requirements, a three-phase generic framework for hybrid simulation has been proposed. Each phase of the framework is mapped to an established requirement and provides guidelines for addressing that requirement. The proposed framework is then evaluated theoretically based on its ability to meet these requirements by using multiple cases, and accordingly modified. It is further evaluated empirically with a single case study comprising of Accident and Emergency department of a London district general hospital. The purpose of this empirical evaluation is to identify the limitations of the framework with regard to the implementation of hybrid models. It is realised during implementation that the modified framework has certain limitations pertaining to the exchange of information between SD and DES models. These limitations are reflected upon and addressed in the final framework. The main contribution of this thesis is the generic framework for hybrid simulation which has been applied within healthcare context. Through an extensive review of existing literature in hybrid simulation, the thesis has also contributed to knowledge in multi-method approaches. A further contribution is that this research has attempted to quantify the impact of intangible benefits of information systems into tangible business process improvements. It is expected that this work will encourage those engaged in simulation (e.g., researchers, practitioners, decision makers) to realise the potential of cross-fertilisation of the two simulation paradigms.

The focus of the research programme within this thesis is an investigation of scenario-based simulation training in undergraduate healthcare education. The aim of the main study was to determine the effectiveness of high-fidelity simulation training with adult branch nursing students. Their acquisition of knowledge and skills was tested using a 15-station Objective Structured Clinical Examination (OSCE) pre- and post- the simulation intervention with randomised control and experimental groups of volunteer students. The results show that simulation training is an effective learning method as students from the experimental group, who were given the opportunity to observe and take part in high-fidelity simulation training followed by debriefing, made significantly higher improvements between their two OSCE performances than students from the control group. The second study focused on interprofessional learning with a randomised control group investigation of the students’ knowledge of the roles and skills of other healthcare professions involved in the same simulation session. The results demonstrate that observing and taking part in multidisciplinary scenarios and their debriefings contributed to the students’ acquisition of knowledge about the roles and skills of other health professionals. The study also showed that students’ perception of multidisciplinary team working was significantly influenced by whether or not they had experienced interprofessional high-fidelity scenario-based simulation training. The main original themes emerging from the research work presented in this thesis comprise the implementation of high-fidelity scenario-based simulation training and debriefing with undergraduate students from a range of healthcare disciplines and the objective measure of the effectiveness of such learning opportunities. This work has now started to impact on simulation practice in undergraduate education within the University and beyond

L’éducation des sciences de la santé repose sur des bases conceptuelles solides et propose de multiples méthodes pédagogiques au service des acquisitions de compétences. La simulation en santé est un des outils à fort potentiel impact pédagogique. Par les diverses modalités, la simulation haute-fidélité permet de travailler les compétences requises lors de gestion de situation critiques médicales avec une forte implication des apprenants, facilitées par un très grand réalisme d’expérience immersive. Le niveau de stress des participants durant les séances de simulation haute-fidélité affecte leurs performances en simulation, leurs acquisitions, leurs mémorisations et leurs comportements ultérieurs en situation réelle.La thèse présentée ici s’est intéressée aux niveaux de stress ressentis des internes, apprenants en simulation haute-fidélité, ainsi qu’à certaines techniques cognitives développées dans le but d’amélioration des acquisitions et de diminution du niveau de stress. La première étude observationnelle relate du niveau de stress et d’anxiété ainsi que des différences observées parmi les internes lors de leur première session de simulation. La seconde étude montre, dans un essai randomisé, l’effet favorable d’une pause relaxation intégrée avant le débriefing du scénario, sur la mémorisation à trois mois des messages clés critiques du scénario. La troisième étude, ancillaire de la seconde, relate les différences de niveaux de stress et de mémorisation entre les apprenants impliqués activement et ceux observateurs du scénario. La quatrième étude est un essai randomisé qui montre l’intérêt d’une concertation pré-critique en équipe pour l’amélioration des performances techniques en simulation. La cinquième étude est un essai randomisé qui montre les effets favorables, sur les performances non-techniques et le stress en simulation, d’une formation à la gestion du stress préalable et d’une réactivation juste avant scénario. La sixième étude est le protocole de recherche d’un prochain essai randomisé qui visera à comparer les niveaux de stress et les performances des internes durant la simulation, après qu’ils aient pratiqué une respiration relaxante standardisée, guidée ou non par biofeedback de cohérence cardiaque et comparé à un groupe contrôle / Medical education, as a pedagogical science, is based on robust conceptual background and offers a variety of teaching methods to optimize the professional competencies development. Simulation in healthcare is certainly one of the tools with great educational impact. Among simulation tools, high-fidelity simulation is one of the newest that allows practicing the management of medical critical situation, with a strong implication of the learners, facilitated by immersion into a realistic experience. The level of stress of participants in high-fidelity simulation sessions affects their performance in simulation, their acquisitions, their memorization and their subsequent behaviours in real-life situations.The present thesis is focusing on the stress levels experienced by learners during high-fidelity simulation and some cognitive techniques developed with the aim of improving acquisition and reducing the stress level. The first observational study is reporting the stress and anxiety levels, as well as the differences observed among residents during their first simulation session. The second study shows, in a randomized trial, the effect of an integrated relaxation break before the debriefing of the scenario that favoured the memorization at three months of the critical key messages of the scenario. The third study, ancillary to the second one, reports differences in the stress level and memorization between learners who were actively involved and those who were just observers of the scenario. The fourth study is a randomized trial that shows the interest of a pre-critical team planning discussion improving technical performance during simulation. The fifth study is a randomized trial that shows the effects of a stress management training and reactivation occurring before the critical scenario that favoured the non-technical performance and stress control during simulation. The sixth study is the research protocol of a future randomized trial that will compare the stress level and performance of residents during simulation scenario, after a standardized relaxation breathing guided or not by cardiac coherence biofeedback and compared to a control group

Cette thèse s’intéresse à l’activité des formateurs en soins infirmiers utilisant la simulation clinique pleine échelle dans leur dispositif de formation. Ce format, basé sur l’apprentissage expérientiel et la réflexivité sur l’action, est considéré comme innovant et complexe à utiliser. Il requiert notamment une remise en question des pratiques pédagogiques habituelles. Notre contribution cherche à identifier ce qui détermine l’engagement des formateurs dans cette activité, et à comprendre comment et selon quelles logiques celui-ci se manifeste dans les pratiques. La recherche croise les cadres théoriques de la théorie sociocognitive de Bandura (1977) et de la didactique professionnelle (Pastré, 1997, 2002) et utilise des modèles de l’engagement et de l’agir enseignant. Notre étude a une visée descriptive des profils d’engagement dans l’activité et une visée compréhensive de leurs manifestations. Le matériau empirique a été obtenu au moyen d’entretiens semi-directifs, d’observations en situation suivies d’entretiens d’autoconfrontation. Il a été traité selon des méthodes qualitatives et quantitatives. Nos résultats montrent un profil dominant, privilégiant des logiques dialogique et herméneutique, et un second profil, sous-tendu par des logiques personnelle et techniciste, ce qui nous permet de proposer une typologie des profils d’engagement dans l’activité. Les pratiques observées et explicitées montrent l’influence du profil d’engagement sur la posture pédagogique. Nous objectivons une forte tension entre une posture de contrôle et une posture de lâcher-prise, cette dernière étant le révélateur d’une transformation en cours dans les pratiques et dans les croyances. / This thesis in education science focuses on the nurse trainers using full-scale clinical simulation in their training plans. This educational tool, based on experiential apprenticeship and reflexivity on the practice, is considered both innovative and complex to use. It especially requires questioning the customary practices of teaching. The author’s has tried to identify what determines and characterizes the commitment of the trainers in this activity, and to understand how and according to which logics that commitment manifests itself at the heart of their practices. The search crossed the sociocognitive theoretical framework of Bandura (1977) and the vocational didactics (Pastré, 1997, 2002); it also used models of commitment and of teaching practice. This study has a descriptive approach of the commitment profiles in the activity and a comprehensive approach of their demonstrations. The empirical material was obtained from semi-directive interviews, observations in situation followed by self-confrontation interviews. It was handled according to qualitative and quantitative mixed methods. The results highlight a dominant profile, favouring the dialogical and hermeneutic logics, and a second profile, underlined by logics rather personal and technical; hence allowing the author to propose a typology of commitment profiles in the activity. The observed and analysed practices reveal the influence of the commitment profile on the educational perspective. A strong tension between a control position and a “let it go” position was identified, the latter being the sign of a transformation in the implementation of learning beliefs.