Practising forethought: the role of mental simulation

Did you know that forethought can be practised? Asking someone how he or she may ‘remember’ the future is an odd question. Particularly so in the clinical simulation community where recall analysis and reminiscence are emphasised over anticipation and prescience. Pre-Briefing is usually a poor relative of debriefing—or so it seems.

There are ample studies that ‘feed forward’ with ‘feedback’ have a stimulus more powerful in learning than other variables in education.¹ Surprisingly this is not so clear for the ‘debrief’. The reason is partly because the terms ‘debrief’ and ‘feedback’ are used so interchangeably. And unlike healthcare, aviation and the military, the word ‘debrief’ is not part of the mainstream educational research vocabulary.

Recent reviews in the healthcare simulation literature attempt to clarify the nature and function of the debrief. Sawyer et al make the distinction that ‘debriefing’ is intrinsically ‘interactive’ and diagnostic, whereas ‘feedback’ is ‘one-way conveyance of information.² Fanning and Gaba refer to the debrief as the ‘heart and soul’ of lifelong learning.³ But these views may be both reductive and overstating the case.

In science, theory directs what researchers and educators do and hindsight analysis legitimises theories by reflection in action and on action. ^{4 5} Consequently models of how to debrief proliferate in health education and become paradigmatic in describing what constitutes good teaching or effective learning, or both. And here is the quandary. In these descriptions of debriefings construed as collective epiphanies a more complex and multidimensional idea of learning risks being collapsed into one which is essentially retrospective and episodic. In the kindred field of counselling, we learn that this overemphasis can be unhelpful, if not detrimental.⁶ Indeed, a pointed criticism of current models of reflection is that they do not sufficiently acknowledge the place of anticipation and forethought.⁷ In other words, they fail to account for how individuals reflect and contemplate on future possibilities.

Not to say that looking back on performance is not important. It clearly is. But the mirroring, the re-experiencing, the diagnosing and the replaying form only one set of functions in the process of improving performance. Weick’s work on high reliability described a particular sensitivity to operations as ‘collective mindfulness’ and a capacity for perspicacity, or ‘goal-driven imaginative enactment’.⁸ Yet curiously, the place of imagination and creativity in contemplating future possibilities with our staff (the task of re-experiencing past events and projecting them into future novel scenarios) is relatively underdeveloped and undertheorised in simulation course design. We tend to forget that the learners before-the-event vision, anticipation and capacity to conjure multiple plots, goals and scenarios is a powerful precondition to improve learning.⁹ As Caroll’s Red Queen remarked: ‘It is a poor sort of memory that only works backwards’.¹⁰

As it turns out, asking whether we can actively draw on (and share) our memories prospectively to lift performance is a growing field of engagement between the social sciences and neurosciences.

It emphasises the importance of what is variably termed ‘mental visualisation’, ‘mental rehearsal’ or ‘mental time travel’. (MTT) The act of remembering the past would appear to have much in common with the act of imagining the future and research has provided strong evidence for extensive overlap between them at the neural, cognitive and phenomenological levels.^{11 12} In addition, a number of supporting studies have emerged in fields as disparate as sport,¹³ music,¹⁴ evolutionary biology¹⁵ and medicine.^16–19

MTT is not the same as ‘briefing as we often understand it in clinical simulation. Cultivating ‘foresight’ is considerably more than a fleeting introduction to the scenario and assigning roles. It draws on our remarkable capacity to combine people, artefacts and actions in our heads in very novel ways and to pre-experience events imaginatively. When this happens, we rehearse and deliberate various ‘what if’ options which in succession expand our opportunities to be prepared for different outcomes.²⁰ An important notion in memory studies is that episodic memory (remembering past events) and episodic future thought (imagining future events) are tightly entwined in our brains. One provides guidance and inspiration for the other to generate simulations of possible future events. In a compelling extension of this notion, Spuznar²¹ refers to people’s capacity for ‘collective future thought’.

Clearly this is a familiar and tangible human behaviour; we can and do speculate about the future with others. So where is the novelty? It lies in the insight that this psychological functioning has given us ‘adaptive advantages’—to be safer and to survive.¹⁵

Erickson and Charness long ago reported how the ability to produce complex representations of the future is the hallmark of individual expertise.²² There is also a large empirical literature reporting investigations of transactive memory and distributed cognition within groups. This demonstrates that the recalling of events to reconstruct and recompose tasks is more effectively done through collective interactions within groups when compared with that done by individuals or groups of non-interacting individuals.²³ So to achieve the dual aims of harnessing collective experience and emulating expert practice, we need to engage with others in order to draw on their memory and foresight; to learn to simulate collectively on what might unfold in the future and how we might adapt.

Here also lies an intriguing ethical dimension. In fact, it is easy to hypothesise with Sutton that a group’s failure to imagine the future together (eg, its team interactions or contingency plans) may lead its members to disengage from the group. Conversely, a group that succeeds in imagining a more synergetic future for itself may strengthen feelings of collective safety and identity. From a functional point of view, then, it is plausible that ‘collective future thinking is, if not more basic than collective remembering, no less basic that it’.²⁴

A key aim for simulation-based learning with hospital staff should be to help us become more articulate in our conversations about practice in order to enhance both learning and safety. The pragmatic question of how we start equipping people in a highly diversified workforce with the interactional competencies to collectively participate in these conversations, therefore, becomes paramount. Whether it is giving or receiving feedback or participating in collective mental simulation, the way we orient people to these tasks is mostly neglected in our educational programmes.²⁵

Clearly confidence using language is vital. In her studies of language and pragmatics, Thomas has argued that people benefit by learning explicitly about strategies for structuring content and conveying intention in their talk. Such active priming can equip them with the socially and professionally acceptable methods for collective circumspection about forthcoming events. Equally importantly it can help them contribute, solicit, receive and respond to ‘feedback’.²⁶ This resonates with Lave and Wenger’s ‘stock of interactional knowledge’ which professionals require to participate in practice effectively.²⁷ We may even need to make more explicit to health professionals the ways we create interaction. This may be our use of language to imagine together (collective mental simulation and ‘feeding up’) and how we then calibrate these expectations with reality (feeding back).

On a practical level, it is not hard to see how the ‘feedback’ conversation which includes prospective and retrospective components begins and can be linked with dialogue around the purposes of the task and the pre-experiencing of it imaginatively. This process introduces opportunities for mental time travel and collective what-if scenarios. The conversation may also allow us to negotiate ways into shared futures by exploring goals in more detail. In this way, individual and collective experiences may intersect with explicit criteria for judging what constitutes good performance.

Collective mental simulation and giving and seeking feedback are ways of hugely multiplying opportunities to promote learning and cultural literacy. But importantly, they are also ways of belonging to a community. While the extent and intensity of dialogue may vary, we must reject the assumptions that feedback is disjointed from feed forward, that it is unilateral and unsolicited or that it is simply retrospective. A primary goal of our hospital-based simulation training should be to build capacity to articulate practices for their own ends and also meta cognitively, for us to become ‘expert’ feed forward/feedback enablers in the workplace.

In our haste to award the ‘debrief’ ‘the honour of being the high point of teaching and learning excellence, we may ignore a broader picture beyond the specific how-to-do-it models. We may fail to challenge some assumptions inherent in these models about how we learn. If future focus is our mental default, and priming before action a pragmatic strategy of individual and collective self-monitoring and feedback, then we can do more to exploit it in simulation-based learning and in practice. The role of imaginative speculation and prospective reflection in performance studies would suggest that we at least try and not leave forethought as an afterthought.