Collaborative learning with screen-based

simulation in health care education: an empirical

study of collaborative patterns and
prociency developmentjcal_407 448..461
L.O. Hll,* T. Sderstrm,* J. Ahlqvist & T. Nilsson
*Department of Education Ume University, S-901 87 Ume, Sweden
Oral and Maxillofacial Radiology, Department of Odontology, Ume University, S-901 85 Ume, Sweden
Abstract This article is about collaborative learning with educational computer-assisted simulation
(ECAS) in health care education. Previous research on training with a radiological virtual
reality simulator has indicated positive effects on learning when compared to a more conven-
tional alternative. Drawing upon the eld of Computer-Supported Collaborative Learning, we
investigate collaborative patterns, their causes, and their implications for learning. We investi-
gate why the extent of application of subject-specic terminology differs between simulation
training and more conventional training. We also investigate howthe student-simulator interac-
tion affordances produce collaborative patterns and impact learning. Prociency tests before
and after training, observations during training, and interviews after training constitute the
empirical foundation. Thirty-six dentistry students volunteered for participation. The results
showed that not only the task but also the medium of feedback impacts the application of
subject-specic terminology. However, no relation to prociency development was revealed.
We identied turn-taking as well as dominance patterns of student-simulator interaction but
again found no relation to prociency development. Further research may give us deeper
insights into if and how these collaborative patterns, in other respects, impact collaborative
learning with ECAS in health care education.
Keywords collaboration, computer, education, health care, learning, simulation.
Introduction
Applications of educational computer-assisted simula-
tions (henceforth called ECAS) are spreading within
health care education (Issenberg et al. 2005; Nehring &
Lashley 2009). This has been described as in part an
effect of a paradigm shift of educational models, from
an apprenticeship model for learning based on experi-
ence to a model based on expertise (Luengo et al. 2009),
although other practical factors are likely to play signi-
cant roles (Gaba 2004). A primary function for the
ECAS is to ensure patients safety through ensuring
practitioners competence when training on actual
patients, and is limited or non-existent (ibid.). Previous
studies have demonstrated both positive as well as nega-
tive effects on skill or prociency development, often in
comparison to available, more traditional alternatives
(e.g. Engum et al. 2003; Quinn et al. 2003; Nilsson
et al. 2007; Sderstrm et al. 2008).
Newtechnologies have a tendency to attract the atten-
tion of educators. Some of which read much hope into
Accepted: 28 September 2010
Correspondence: Lars O. Hll, Department of Education, Ume Uni-
versity, S-901 87 Ume, Sweden. Email: lars-olof.hall@pedag.umu.se
doi: 10.1111/j.1365-2729.2011.00407.x
Original article
448 2011 Blackwell Publishing Ltd Journal of Computer Assisted Learning (2011), 27, 448461
them for the realization of their educational ideals,
while others view them as threats to the current educa-
tional canon (Cuban 2001; Dillenbourg et al. 2009;
Slj 2010). The tension between enthusiasts and critics
can create an initial dichotomy of general statements
about the technologies effect on education and black
box comparisons of new versus old media. This ten-
dency can be traced in the earlier research of health care
simulation as well (e.g. Abrahamson et al. 1969; Ovasa-
pian et al. 1988; Chopra et al. 1994; Peugnet et al.
1998). However, the tension between enthusiasts and
critics can also drive the research to be more nuanced
and practice-oriented studies where the technique of
using the technologies enter focus. Later research on
health care simulations seem to have shifted to this
focus. (Gaba 2004; Issenberg et al. 2005; McGaghie
et al. 2010). It is to this research that we want to contrib-
ute by adding collaborative learning to the equation.
From a Computer-Supported Collaborative Learn-
ings (CSCL) perspective, collaborative activities may
be put forward as a framework technique to improve
training efciency with this type of technology (e.g.
Crook 1994; OMalley 1995; Koschmann 1996; Dillen-
bourg et al. 2009). Collaboration is, however, not con-
sidered to support learning automatically, and a general
CSCL question for Dillenbourg is thus under which
conditions is collaborative learning effective? with the
sub-questions under what conditions do specic inter-
action patterns occur, and what interaction patterns
predict learning outcomes? (ibid. p. 6). These general
questions are valid also for this study of learning with an
ECAS in dentistry education.
Within the research project Learning Radiology in
Simulated Environments, we have studied collabora-
tive learning with one type of ECAS, a screen-based
virtual reality (VR) simulator
1
(Sderstrmet al. 2008).
In a prior paper, we presented comparative data on pro-
ciency development and collaborative patterns for stu-
dents training with the simulator (the SIM group), as
contrasted to students working with a more conven-
tional PowerPoint-based exercise (the CON group). In
short, we found that while collaboration in the CON
groups seemed to be more in line with our ideals, e.g.
with more inclusive peer discussions, more thorough
interpretations of what is shown on screen and more
extensive application of subject-specic terminology, it
was the SIM groups that developed more with regard to
prociency development (ibid.). Others have argued
that students may work with software without much
reection or change in their conceptual understanding,
and argued for the benets of thorough dialogue (e.g.
Pilkington &Parker-Jones 1996; Pilkington 1998). This
discrepancy thus intrigued us and is part of our motiva-
tion to keep analyzing this data.
In this article, we will continue the analysis of col-
laborative learning with the radiological VR simulator.
It is written in the intersection between the empirical
research eld of learning with ECAS within health care
education and the general research eld of CSCL.
Based on Dillenbourgs general questions, two themes
will be investigated, described in the next section along
with the empirical questions about observed collabora-
tive patterns, their causes, and their impact on learning
for dentistry students training collaboratively with the
radiological VR simulator.
The rst theme is about a specic collaborative
pattern, the application of subject-specic terminology
during the training session. In sociocultural perspec-
tives on learning, action with cultural tools or medita-
tional means is one central concept (e.g. Wertsch 1998;
Slj 2010). These tools can be physical artefacts such
as an X-ray machine, as well as mental systems such as
parallax technique for interpreting X-ray photographs.
Some argue that a key aspect of adult learning, such as
professional learning of the practice of radiological
examinations, lies in the mastery of the cultural tools
required for competent action within this practice. This
mastery entails not only developing competence in
applying specic tools but also being able to choose
appropriate tools and design solutions to specic tasks
(Slj 1999, 2000, 2010). Verbal interaction is a recur-
ring focus of sociocultural studies because it can reveal
participants use of mental tools and collaborative foci
(e.g. Enyedy 2003; Mercer 2005), as well as non-verbal
actions and interactions have proven to be valuable ele-
ments of observation when researching health care edu-
cation (e.g. Hindmarsh 2010). In this article, the
application of subject-specic terminology is regarded
as a visible indicator of students trying to use cultural
tools from specic subject areas. The extent to which
groups in SIM and CON apply subject-specic termi-
nology during training was analysed, and it was found
that SIM groups tend to apply them to a signicantly
lesser degree (Sderstrm et al. 2008). The empirical
questions for this theme are (1) [W]hat causes the extent
of application of subject-specic terminology to differ
Collaboration and educational simulations 449
2011 Blackwell Publishing Ltd
between groups working with the ECAS (SIM) and
groups working conventionally (CON)? and (2) [W]hat,
if any, implications does the extent of application
of subject-specic terminology have for prociency
development?
The second theme is about one of the fundaments of
ECAS, the physical interaction with the simulator itself,
and how this impacts collaboration and learning. The
physical studentsimulator interaction is essential for
enabling students to inquire or discover (e.g. Lazonder
et al. 2010) that which is simulated, or to learn to
performit (e.g. Engumet al. 2003). With a screen-based
simulator such as the one under scrutiny here, manoeu-
vring the simulator became a central activity. While all
participants are able to see the screen at any given
moment, they cannot all manoeuvre it at the same time.
This separates it fromsome full body computer assisted
mannequins, or integrated simulators (Bradley 2006),
where participants interact with different parts of the
simulator. Manoeuvring the simulator means control-
ling what is shown on screen and has thus a direct
impact on what visual information is available to the
group. It is thus justied to investigate how the physical
student-simulator interaction affordances impact col-
laboration and learning. The empirical questions for this
theme are (3) [A]re there distinguishable patterns of
how students share control over the simulator?; (4)
[D]o the patterns of control over the simulator on the
group level, or time spent manoeuvring the simulator on
the individual level directly impact prociency develop-
ment?; (5) [D]o specic patterns of control over the
simulator produce specic patterns of verbal interac-
tion and does individual control over the simulator also
entail control over the verbal interaction?; (6) [A]re the
verbal patterns or individual control over the verbal
interaction directly related to prociency develop-
ment?; and (7) [H]owis the group collaboration around
the studentsimulator interaction perceived by the stu-
dents themselves?
This article contributes to the growing interest of
techniques for using ECAS in health care education.
Drawing upon the eld of CSCL we will contribute to
the investigation of collaborative learning as such, a
technique with focus on relationships between cultural
tools, interactive patterns, and learning. How does the
transition from one tool (MS PowerPoint) to another
(screen-based VR simulation) impact the application of
other tools (subject-specic terminology), peer collabo-
ration and learning outcomes? Can we discern charac-
teristics of the tools central to these effects? What are
the implications for designing for collaborative learning
with screen-based simulations in health care education
and for future research on the subject?
Method
This study was built around a quasi-experimental core.
Participants were recruited from a population of under-
graduate students in the dentistry program at Ume
University, Sweden, attending a course in Oral and
Maxillofacial Radiology. Thirty-six students 20
female and 16 male volunteered. The core of the
design was that (1) [I]nitially, all participants performed
a prociency test. (2) [A]n experimental group (SIM)
and a control group (CON) were formed, with 18 stu-
dents in each group, matched to be comparable on the
prociency test. Within the respective group, six work
groups of three students were randomly created, result-
ing in six SIM groups and six CON groups. (3) [T]he
workgroups received training on the subject of object
localization using parallax principles, i.e. analysing
multiple X-ray photographs of a jaw in order to identify
and position potential anomalies in relation to generic
anatomical objects such as specic teeth. During this
training SIM used a screen-based simulator and CON
used a set of MSPowerPoint slides. These sessions were
recorded on video. (4) [A]ll students performed a
second prociency test after training. Later on 18
participants, nine from each group, participated in
follow-up interviews. This design is illustrated in
Table 1. Each of these elements is explained further
in the next section.
The prociency tests
The students prociency in interpreting radiographs
was evaluated before and after the exercises. The instru-
ment used, a prociency test, was developed by two
dental scientists who teach at the dentistry program. It
measured what right now counts as subject prociency
in this course at the dentistry program.
The tests consisted of three subtests: a principle test, a
projection test, and a radiography test; each part graded
from 08 giving a total of 24 points. The principle
subtest aimed at assessing the participants understand-
ing of the principles of motion parallax. The projection
450 L.O. Hll et al.
2011 Blackwell Publishing Ltd
subtest aimed at assessing the participants ability to
apply the principles of motion parallax. Based on basic
sketches, this subtest requires basic understanding of
anatomy. The radiography subtest aimed at assessing
the participants ability to locate object details in
authentic radiographic images utilizing motion paral-
lax. The participants were asked to report the relative
depth of specied object details in pairs of radiographs.
The prociency analyses in this study are based on the
total score from all three tests.
Training sessions and simulator
The training session settings were comparable for the
SIM and CON groups, with the exception of software
and computer peripherals. The training tasks focused on
object localization using the principles of parallax. The
work groups (with three students in each group) were
located in front of a PC equipped with either the radio-
logical VRsimulation software, illustrated in Fig 1, or a
set of PowerPoint slides with images and written tasks
and subsequent answers, illustrated in Fig 2. Please note
that while Fig 1 illustrates single-user simulation train-
ing, the training discussed in this article was performed
in workgroups with three students in front of the
screens. A passive teacher was available during the
60-min-long sessions.
The simulator was basically a PC equipped with
simulation software, two monitors, and some special
peripherals. Special glasses were worn by all group
members to enhance the simulators 3D effects. One of
the monitors represented 3D models of a patient,
camera, and lm. The other represented virtual X-ray
photographs. The control peripherals used for interac-
tion include a standard keyboard, a 3D mouse, and a
pen-like controlling device. While the keyboard is used
scarcely, the pen and the mouse are central to manoeu-
vring the simulator.
Using the simulator, the students were able to col-
laboratively perform real-time radiographic examina-
tions of patients teeth. It allowed the students to
position the three-dimensional model of the patient, the
X-ray tube, and the lm. X-ray images could then be
Table 1. Design of the study.
Input Process Output
Variable Pre-training
prociency
Training SIM Post-training prociency
Training CON Experience
Evaluation
of variable
Prociency test Observation Prociency test
Survey
Interviews
SIM, simulator; CON, control.
Fig 1 Illustration of a single-user training with the radiological VR
simulator. During actual training, workgroups of three students
collaborated in-front of these screens.
Ange andring i proojekion mellan bild (1), (2), och (3).
Lagesbestam mesiodensen i forhallande till angransande tanders rotter.
Fig 2 Example of an MS PowerPoint slide from the CON group
training.
The textual feedback given in this image read as follows. Line 1
states the alteration in projection between image (1), (2), and (3).
Line 2 locates the mesiodens in relation to the roots of adjacent
teeth.
Collaboration and educational simulations 451
2011 Blackwell Publishing Ltd
exposed at will by students, immediately presented by
the simulator as geometrically correct radiographs ren-
dered from the positions of the models. Four types of
exercises centred on object localization were included.
In the fourth exercise, it was possible to view the two-
dimensional X-ray image change in real time as the
model was manipulated. For further technical specica-
tions and discussion of validity, see Nilsson (2007).
Video-recorded observation
Like many other researchers of health care education
(e.g. Hindmarsh 2010; Koschmann et al. 2010) and
educational health care simulations (e.g. Rystedt &
Lindwall 2004), we have used video-based observations
to capture learning in practice. To enable analysis and
comparisons of group interaction during training, the
training sessions were recorded using a DV camera.
Twelve groups meant twelve one-hour recordings. The
camera was placed so that the upper half part of the stu-
dents was visible while neither the computer screen
nor the teacher was visible.
The analysis of group interaction during training was
performed through two phases. In phase one, three
questions were posed to a number of randomly chosen
video recorded training sessions. These questions
resulted in detailed descriptions from which thematic
categories of group interaction were inferred. These
questions were, [W]hat are the participants talking
about? How are they talking about it? How do they
relate to each other and to the learning environment as a
whole? When no more categories were found, i.e. satu-
ration had been reached, phase one ended. In phase
two, all video data was split into one-minute time
segments and coded with the previously abstracted
thematic categories. In our descriptive presentations
of the observations (such as Tables 2 and 4, or Figs 3
and 4), these time-segments are our empirical unit of
observation. The categories were limited to whether
the content of the conversation was action-oriented,
interpretive, technology-focused, meta-reective, theo-
retical or social; whether or not subject-specic termi-
nology applied; which member was manoeuvring the
simulator; which members were active in the conversa-
tion; which, if any, member had command over the
verbal space. This allowed us to conduct a highly struc-
tured analysis based on an understanding that was
inuenced by the current set of data.
The coding of video recorded sessions was per-
formed by one of the researchers. In order to produce
a measure of the coding stability (Krippendorff
2004), one of the sessions was re-coded, by the same
researcher, and compared with the original for each cat-
egory described above. The per cent agreement between
original coding and re-coding was 97% for content,
92% for terminology, and 98% for manoeuvre, verbal
space, and verbal activity, respectively.
Follow-up interviews
After an initial analysis, follow-up interviews were per-
formed with one half (18) of the participants. The aim
was to better understand the training experience in SIM,
how it differs from CON and to better understand the
observed differences between the two. With open-ended
questions, we talked about the respondent as a learner,
training impact on learning, the respondent as a group
member, the tasks, realism and functionality. These
interviews included 18 participants in total, nine from
the respective group. They were performed individually
with an effective time usage of 3050 min, during a
period of 2 weeks. Video recordings of the respondents
training session were played on a laptop computer to
support recall. All interviews were recorded on tape. A
qualitative approach was adopted in the analysis focus-
ing on inferring categories of responses, sometimes
called meaning concentration (Kvale & Brinkmann
2009), rather than a quantitative count of howmany said
what, i.e. we posed specic questions to each transcript,
extracted the responses related to it, and inferred catego-
ries of ideas from these responses. The end product is
illustrated in Table 2, where categories of respondent
ideas about reasons for using subject-specic terminol-
ogy is presented along with quotes that fall into each cat-
egory. A selection of results will be presented as the
different categories of responses identied within the
SIM group or in the SIM and CON groups. Quotes of
student responses have been translated from Swedish
into English.
Results and analysis
Application of subject-specic terminology
As previously mentioned, there was a signicant
difference between SIM and CON with regard to the
452 L.O. Hll et al.
2011 Blackwell Publishing Ltd
frequency with which they applied a subject-specic
terminology as opposed to subject-non-specic termi-
nology (Sderstrm et al. 2008). The question we pose
here is, what causes the extent of application of subject-
specic terminology to differ between groups working
with the ECAS (SIM) and groups working convention-
ally (CON)?
The rst step was asking the students themselves,
through interviews, why they were using the subject-
specic terms during training. As a group, the students
presented a few thematic reasons, not all of them com-
patible with one another, for using these terms. These
are presented in Table 2 and include (1) The terms
enable communication; they are the only words they
know (for projection and anatomy). (2) Students all
share the same understanding of the terms. (3) The
terms make communication easier and more efcient.
The alternative, using everyday words, would be more
complicated. (4) Teachers have previously encou-
raged students to use them. (5) The solution to the
tasks is supposed to be presented in these terms
(CON only).
When trying to understand what caused differences
between SIM and CON, there are two particularly
interesting themes in these responses. The rst is the
idea put forward in CON that the solution was sup-
posed to be presented in subject-specic terms (4). As
one of the CON students puts it, [example (5) in
Table 2], Because in the answer you are supposed to
respond, this is more distal or more mesial. That makes
it easier if you communicate in that way from the
beginning.
It was, however, not the case that the students were
required to produce a solution in the subject-specic
terms. The students in the CON groups were, however,
required to describe changes in projection between
images and to describe the relation among certain
objects. As indicated by the responses, the students
found it much easier to do so by using terms for
projection and anatomy than by using everyday lan-
guage. However, the feedback after each task was in
CON, the correct solution if you will, given as one-
sentence descriptions in subject-specic terms. This
suggests that for the students, the correct answer may
tend to be identical to the one written by the teacher.
The SIM students were also required to interpret
projection and locate objects but, and this is a signi-
cant difference, they were tasked to manoeuvre the
model based on this interpretation. And the feedback
they were given is in part visual, a correct positioning
of the model was shown, and numerical, the distance or
angle between the students position and the correct
position was shown in numbers. If the medium of
feedback impacts the process, then this would explain
part of the difference in the application of subject-
specic terminology. It would also indicate that if
Table 2. Categorization of respondents answers to the question of why they use the academic terminology during training.
Inferred category Example quote Present in group
(1) Terms enable
communication
(1) We cant just say that this tooth is . . . we have to say that it is distal
on this tooth. That is the term we have learned for that trajectory.
Both
(2) These are the only words we have. It would not work without
them.
Both
(2) Students share
understanding of the
terms
Because we have learned them all three of us know what we are
talking about, because it is correct. If we say buccal everyone in the
group understands.
Both
(3) Terms make
communication efcient
It is easier to work with my classmates if we can use these terms. There
is a lot of anatomy we have to learn.
Both
(4) Prior teachers orders We wouldnt have if the teachers hadnt forced us to start using them.
It is the language you are supposed to use when working and
writing.
Both
(5) The solution is to be
presented in these terms
Because in the answer you are supposed to respond: this is more distal
or more mesial. That makes it easier if you communicate that way
from the beginning.
CON
n = 18.
CON, control.
Collaboration and educational simulations 453
2011 Blackwell Publishing Ltd
SIM students were given textual feedback similar
to that in CON, then there would be an increase in their
use of these terms.
The second thing to note in the responses is that the
subject-specic terms were associated with anatomy
and projection, as illustrated here by the example
quotes for (1) and (3) in Table 2. In other words,
these terms were especially relevant when trying
to interpret changes in projection and to locate
objects. They were not necessarily central for manoeu-
vring the simulator. This suggested that there should
be a positive relationship in the observational data
between what students talked about and the terminol-
ogy they used for talking about it. As illustrated by
Table 3, such relations do exist. When the content of
the verbal interaction was interpretations, SIM students
applied subject-specic terms to a much greater extent,
as compared to when the content was action-oriented
(64.5% of cases compared to 11.4%, chi square 93.8;
P < 0.001).
This means that the differences in tasks between SIM
and CON, which encourage more focus on action for
SIM, impact the application of subject-specic termi-
nology. However, when comparing the interpretive
content of SIM and CON, it is apparent that CON
students still apply subject-specic terms much more
often (90.5% of all interpretive instances compared to
64.5% for SIM, chi square 46.4; P < 0.001). We con-
clude that while differences in tasks impact the extent of
application of subject-specic terminology, this does
not explain all of the difference between the SIM and
CON. We suggest that the medium of feedback is also
important.
The second question for this theme is, what, if any,
implications does the extent of application of subject-
specic terminology have for prociency development?
Table 4 illustrates how often SIM groups applied
subject-specic terminology (as the percentage of the
observational time-segments in which they occur), in
relation to group prociency development. It reveals
that the group that most often applies subject-specic
terms, SIM 2, also develops most (14 points); it also
reveals that the group that most rarely applies these
terms, SIM 4, develops the least (-2 points). These two
cases do, however, seem to be exceptions to a pattern of
randomness, because there is no relation between the
two factors in the remaining four groups (Spearmans
r 0.6; P > 0.05). We conclude that the extent of appli-
cation of subject-specic terminology have little direct
impact on prociency development.
Table 3. Comparison of how verbal
content and applied terminology
co-appear for SIM and CON groups.
Training Verbal content Subject-specic
terminology
Not subject-specic
terminology
CON Interpretation 90.5% 9.5%
Action-oriented 10% 90%
SIM Interpretation 64.5% 35.5%
Action-oriented 11.4% 88.6%
Percentage based on the total number of observational time segments where the
category is identied.
CON, control; SIM, simulator.
Table 4. Extent of application of subject-
specic terminology in relation to group
prociency development, divided by SIM
group.
Group Subject-specic terminology Group prociency development
SIM 1 41% 2
SIM 2 46% 14
SIM 3 37% 10
SIM 4 10% -2
SIM 5 28% 9
SIM 6 30% 3
Percentage based on the total number of time segments for the respective group.
SIM, simulator.
454 L.O. Hll et al.
2011 Blackwell Publishing Ltd
Student-simulator interaction affordances
manoeuvring the simulator
Are there distinguishable patterns for how students
share control over the simulator?As illustrated in Fig 3,
the observations revealed two types of collaboration
around the student-simulator interaction. The rst one,
illustrated by SIM 1, SIM 2, SIM 4, and SIM 5, is char-
acterized by manoeuvral turn-taking. Each group
member got a chance to manoeuvre the simulator, albeit
not for an equal amount of time. The second one, illus-
trated by SIM3 and SIM6, is characterized by manoeu-
vral dominance where one of the members operated the
simulator almost all the time. Acommon characteristic
of the manoeuvral dominance groups was that the
member sitting in the middle, right in front of the com-
puter, was the one manoeuvring the simulator. When
asked, through interviews, if the choice of seat was con-
scious, the dominant female operating the simulator in
SIM 6 claimed, I decided to sit in the middle . . . I want
to have control and take command. Most students
claim, however, that it was not conscious. We conclude
that SIM groups differ in their sharing of control over
the simulator and that there are two distinguishable col-
laborative patterns, turn-taking and dominance.
Do the patterns of control over the simulator on the
group level, or time spent manoeuvring the simulator on
the individual level, directly impact prociency devel-
opment? As illustrated by Table 5, there are better and
worse developments for groups characterized by turn-
taking (2, 14, -2, 9 points of development, respectively)
as well as dominance (10, 3 points of development,
respectively). On the individual level, there seems to be
no clear-cut relationship between time spent manoeu-
vring the simulator and prociency development
(Spearmans r 0.1; P > 0.05). The operators in the
Fig 3 Illustration of the time spent by each group member manoeuvring the simulator.
Members of each group are labelled after their position in front of the computer: left, middle, or right.
Collaboration and educational simulations 455
2011 Blackwell Publishing Ltd
dominance groups, SIM 3 and SIM 6, developed a little
more than their next-best group member (2 and 1 points
better, respectively). And the primary operators in the
turn-taking groups developed equally (SIM 2) or less
(SIM 1, 4, 5) in comparison to their group members. In
one of the groups, SIM 5, the member with the least
amount of manoeuvring-time developed much more
than her peers (7 points in comparison to 2 and 0). We
conclude that neither the patterns of control over the
simulator nor the time spent manoeuvring the simulator
directly impact prociency development.
Do specic patterns of control over the simulator
produce specic patterns of verbal interaction, and
does individual control over the simulator also entail
control over the verbal interaction? Figure 4 illustrates
howoften a given member has command over the verbal
space in the respective SIM group. Beginning with the
turn-taking SIM 1, the verbal pattern was signicantly
different from the manoeuvral pattern with one person
dominating the verbal space throughout the training
session. In the similar turn-taking group SIM5, a differ-
ent pattern appears, a distinct dyadic pattern with two
members in tight communication. Moving to SIM 4, a
manoeuvral dominance group, we nd that the member
that operated the simulator throughout the training
session rarely took command of the verbal space. But in
the similar SIM6, the dominant operator also took clear
command of the verbal space. We conclude that specic
patterns of control over the simulator do not produce
specic patterns of verbal interaction. Nor does indi-
vidual control over the simulator also entail control
over the verbal interaction. We nd two patterns of
verbal interaction, one dyad-ish and one based on
dominance.
Are the verbal patterns or individual control over the
verbal interaction related to prociency development?
Regarding SIM 2, 3, 4, 5 as variations of a dyadic
pattern with one more or less dominant member, and
SIM 1 and 6 as variations of a dominance pattern, there
is no clear-cut relation between verbal pattern and pro-
ciency development. Developments in the dominance
groups were weak (2, 3 points, respectively), and some-
what varied in the dyad-ish groups (14, 10, -2, 9,
respectively). The fact that SIM 1 and SIM 6 were char-
acterized by having one particularly strong member
who developed very little with regard to prociency
test scores (1 and 2 points, respectively) would also
suggest that dominance does not ensure the individuals
development, and also seems to do little to help the other
members. However, because the verbally shy member
Table 5. Manoeuvral patterns and prociency test scores and development for SIM groups and individual SIM group members.
Group Man. pattern Member* Pre test score Post test score Development Group dev.**
SIM 1 Turn-taking Left 19 19 0
Middle 15 16 1
Right 15 16 1 2
SIM 2 Turn-taking Left 7 14 7
Middle 5 12 7
Right 16 16 0 14
SIM 3 Dominance Left 12 15 3
Middle 13 18 5
Right 11 13 2 10
SIM 4 Turn-taking Left 7 7 0
Middle 18 15 -3
Right 14 15 1 -2
SIM 5 Turn-taking Left 8 15 7
Middle 14 16 2
Right 20 20 0 9
SIM 6 Dominance Left 16 17 1
Middle 10 12 2
Right 13 13 0 3
*Group members are described by their physical position in front of the simulator.
**Group dev. is the combined development score for members of a given group.
SIM, simulator.
456 L.O. Hll et al.
2011 Blackwell Publishing Ltd
in SIM 5 gained so much (7 points), the data gives no
clear-cut support for the opposite either, that mutual
regulation of the verbal space is essential for collabora-
tion to be effective with regard to prociency develop-
ment. No signicant correlation between individual
control over the verbal space and prociency develop-
ment was found (Spearmans r -0.05; P > 0.05). We
conclude that neither the verbal pattern nor individual
control over the verbal interaction is directly related to
prociency development.
How is the group collaboration around the student-
simulator interaction perceived by the students them-
selves?The interviews showed that the SIMstudents are
aware that some members spend more time operating
the simulator and that some members have more inu-
ence on the verbal interaction. Table 6 illustrates six cat-
egories of factors put forward by students to explain
these differences. (1) Personality: some people want to
lead and others do not, and this determines a persons
behaviour in the specic collaboration. (2) Social rela-
tions: two members are more familiar with each other
encouraging a dyad-ish interaction. (3) Competence:
members subject competence varies and this decides
how central they are to the collaboration. (4) Techno-
logical: position in front of the computer determines
how central members are to the collaboration. (5)
Chance: members behaviour varies from day to day
due to factors such as fatigue. Similar topics were raised
when the students were asked to make suggestions
for how to support group collaboration. We conclude
Fig 4 Illustration of how often group members dominate the verbal space.
Members of each group are labelled after their position in front of the computer: left, middle, or right.
Collaboration and educational simulations 457
2011 Blackwell Publishing Ltd
that the students are aware of the unequal distri-
bution of control over the simulator and the verbal
space. They posit four categories of explanations as to
why this occurs, individual, social, technological, and
contextual.
Summary and discussion
This article has contributed to the investigation of col-
laboration as a technique for using ECAS in health care
education. We have focused on relations between tools,
collaboration and learning, and specically on two
themes. First, causes and effects of the extent of applica-
tion of subject-specic terminology. Second, patterns
of collaboration around the student-simulator interac-
tion and the effects of these patterns on prociency
development.
Observing SIM and CON groups side by side origi-
nally made it obvious that students training conven-
tionally made use of subject-specic terminology to a
much greater extent than students working with the
ECAS. In this article, we have argued that these terms
are part of cultural tools associated with academic
domains of anatomy and projection, and that these are
more tightly associated with interpretive activity as con-
trasted with the action-oriented activity that is required
by simulation tasks. This suggests that the differences
are, in part, explained by differences in what the stu-
dents are tasked to achieve. We argue, however, that the
differences in tasks do not explain all the difference
in applications of subject-specic terminology and
propose that the mediumof feedback may also be part of
the explanation. While SIM students were given visual
and numeric feedback, CON students were given
textual feedback in subject-specic terms. If this
hypothesis is true, that a certain characteristic of the
tools, the medium of feedback, contribute to these
effects, then SIM students would increase their applica-
tion of subject-specic terminology if given textual
feedback similar to that given in CON. Further research
may yield more information about how different media
of feedback after subtask completion impacts the col-
laborative process and learning outcomes. We have,
however, found no clear-cut relation between the extent
of application of subject-specic terminology and
prociency development within the SIM groups. It is
possible that a more qualitative analysis, following the
students problem-solving processes, is necessary to
make useful associations between collaborative pat-
terns of tool usage and prociency development. It is
also possible that collaborating extensively with
subject-specic terms has other benets than what is
evaluated by prociency tests such as the one used in
this study.
When training with an ECAS, interaction with the
simulator is essential, and depending on the type of
simulator, the hands-on physical interaction may be
more or less central to the collaboration. We studied
how the physical student simulator-interaction affor-
dances impact collaboration and prociency develop-
ment. Observations of the SIM groups made it obvious
howcontrol over the simulator is shared and not shared,
Table 6. Categorization of respondent (SIM only) statements
about differences in time spent manoeuvring the simulator and
verbal space.
Inferred category Example quote
(a) Personality 1) I am one of those that are not
afraid to speak my mind, and I can
be completely wrong. I am very
active in classes too, ask a lot, Im
not someone to sit quiet and think.
Me and X talk much more, but I see
that as natural, thats just the way it
is, she is much less talkative than
me and X.
2) I dont want to be the one leading
the discussion, or lead anything at
all. Maybe I rather listen and then
Ill speak if something gets strange.
Better to let those lead who want
to lead.
(b) Social
relations
But also that I and X are pretty familiar
with each other. We already knew
each other well.
(c) Competence 1) X is very good at these things, so
one tends to trust him.
2) Im the one that in most cases takes
the initiative in presentations,
transcriptions etc. It is probably
because if I do it, it is done
correctly.
(d) Technological I also think that you get to hold it
more if you sit in the middle.
(e) Contextual It also depends on what day it is, if you
are tired etc. Some days you just
want to listen.
n = 9.
SIM, simulator.
458 L.O. Hll et al.
2011 Blackwell Publishing Ltd
but it is harder to knowif and howthis impacts learning.
We have shown that there are two distinct collaborative
patterns for sharing control over the simulator. One was
characterized by turn-taking, albeit with different
degrees of equality, and the other by one-member domi-
nance. Both turn-taking and dominance patterns
produce both better and worse group prociency devel-
opment, suggesting that neither pattern is in itself better.
In the two dominance groups, being the sole operator
may have been slightly benecial, but in the turn-taking
groups the impact on prociency development was
varied.
We also studied whether these two patterns produced
specic patterns of verbal interaction. Observations
revealed differences in how the verbal space is distrib-
uted among group members. We found a dominance
pattern, where one of the members has command over
the verbal space almost all the time. We also found
variations of a dyad-ish pattern where a somewhat
dominant member shares more or less space with one of
the other members while tending to exclude the third.
There was, however, no clear-cut relationship between
the patterns of control over the simulator and the pat-
terns of control over the verbal space. Nor was there a
clear-cut relationship, on the individual level, between
controlling the simulator and controlling the verbal
space. We also found no relationship between pro-
ciency development and verbal pattern, or individual
control over verbal space. Further research may give us
deeper insights into if and how these collaborative pat-
terns, in other respects, impact collaborative learning
with ECAS in health care education. This is, however,
an illustration of Sljs suggestion that technologies
have implications for social activities, some of which
may be foreseen and others which materializes as the
technology becomes integrated into specic activities
(2010, p. 54).
The students themselves were aware of the differ-
ences in the distribution of verbal space and control over
the simulator. When trying to explain it and when sug-
gesting how collaboration can be optimized, they name
factors such as personality, social relationships, compe-
tence, position in front of the computer and chance. The
fact that students have ideas about whomthey think they
would collaborate well with lead to ideas about student-
regulated matchmaking and group creation mecha-
nisms. According to Wessner and Pster (2001),
[G]roup formation in CSCL environments is either
done manually with little support fromthe system, or the
system needs an elaborated model of the learning
domain in order to select potential peer learners and to
form learning groups in a pedagogically sound way.
Because our students had studied together as a class for
about 2 years, it would have been interesting to know
how the collaborative training with this VR simulator
would have been affected by such a simple thing as
having students create their own groups. Would they in
practice have teamed up with individuals that enhanced
collaboration, or just made the training more social?
Then again, maybe there is a professional value in stu-
dents continuously learning to collaborate with different
individuals irrespective of their personal differences?
Either way, the social composition along of groups is
one important aspect toconsider, alongwiththe collabo-
rative activities and the technological support, when
designing CSCLenvironments (Stahl 2004, p. 87)
As with any scientic method, we set limitations for
the generalizations possible to make from the empirical
data, and some of them need to be mentioned. One of
these limitations is that the comparisons made on group
level are made with a relatively small number of units,
six. This means that we need to be cautious in making
statistical generalizations from these comparisons.
They do, however, serve a purpose as indicators of the
state of our simulation training. This is why we have
given descriptive statistics a prominent role when
dealing with relationships between group level patterns.
The limitations in space have also required us to focus
on some issues and leave others for future papers, such
as further analysis of the interrelationships between
factors considered in this text. It is possible for instance
that there is a positive correlation between application
of subject-specic terminology and prociency devel-
opment but that this effect is countered by factors such
as group interaction patterns. Introducing simulator
logs of student activity, such as time on task and perfor-
mance on tasks could also enrich our understanding of
the matter.
One nal thing must be noted about the value of col-
laboration. The mean prociency development for the
collaborative SIM groups in this study, a signicant
two-point development, is identical to that found by
Nilsson et al. (2007) for comparable students training
individually with the same radiological VR simulator.
That is, having students train individually and having
them work collaboratively in groups of three, in the
Collaboration and educational simulations 459
2011 Blackwell Publishing Ltd
manner they did in this study, seem to make no differ-
ence with regard to the groups mean prociency devel-
opment. We may be able to enhance our support for
collaboration by identifying benecial collaborative
patterns and encouraging these during training as Dil-
lenbourg et al. (2009) suggests, thereby supporting stu-
dents prociency development. But, are we not equally
likely to be able to enhance support for individual train-
ing to make that more efcient? Is this a type of screen-
based simulation training, and training with ECAS in
general, activities where the answer to the how do we
optimize training efciency question should generally
be answered by collaborative activity? These questions
are related to the questions of what we want to achieve
with education and what part of this we can, and do,
evaluate with student examinations. Some would say
that collaboration has benets other than that of learn-
ing to solve the task at hand, like developing critical
thinking (e.g. Gokhale 1995), and that it is necessary
to achieve certain learning goals (Kirschner et al. 2004).
As long as ECAS continues to spread in health care edu-
cation, be it because of a paradigm shift in educational
models or because of other factors, research needs to
help us better understand how to support students when
training with them, irrespective of whether the training
is done collaboratively or individually.
Note
1
For topological discussions of ECAS in health care see examples for Gaba
(2004) and Nehring and Lashley (2009).
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