Table 1.

The use of Complexity theory to support simulation deployment

Complexity theory element	Description9	Application to design (outcome to simulation intervention highlighted in bold)
Emergence	Emergence relies on non-linear dynamics of internal interactions among a quantity of diverse elements, such as diverse ways of thinking and acting, or diverse information	▸ Learner groups needed both differentiation and integration—It was decided that ‘authentic’ teams of multidisciplinary learners must be employed. ▸ Coaching to support outcome based process planning—in the context of SECTORS allowing integrated team based situational awareness and shared mental models.12 This was fostered through a dedicated session for more in depth debrief.
Attunement	Both close listening and observing, as well as touching, intuiting and affective sensing of what is unfolding in the webs of relations in which one is acting with their colleagues	▸ Involve real multidisciplinary teams with members of different specialities and levels of expertise, including undergraduate and postgraduate trainees) in ratios that are ‘authentic’ to the workplace. ▸ Through the use of debrief, support individual learner to observe peers as well as their own behaviours, gain insight into their own performance and to model behaviour and knowledge to inform self-efficacy13 and team situational awareness (SECTORS6)—therefore it was decided to have a two stage debrief, with an initial immediate session to allow learners to consider their own actions and an extended debrief in a separate section with faculty edited led debrief to support learners considering their peers ▸ In designing assessment, it was decided that observation of actual interaction was key in judging learning
Disturbance and nested systems	Systems are nested rather than distinct, with learning occurring through disturbance of these nested systems	▸ Scenarios were designed to lend themselves to disturbance through commotion and complexity of the scenarios ▸ Planned disturbances and error triggers were integrated into the scenarios to ensure disturbance occurred and enhance error awareness (SECTORS6) ▸ Assessment was to be based on consideration of disturbance in the context of non-technical skills.
Experimentation	A complex system learns because elements in such a system experiment with the alternatives that are continuously generated	▸ Multiple sources of authentic feedback were integrated into the scenarios. The led to the building of a second scenario that was described as a ‘chamber of horrors’ allowing a number of the items experimented within in the first scenario to be revisited and considered. Multidisciplinary teams discussed each item, allowing a positive feedback loop to occur to consolidate learning.