Authors: Tabitha Ford, MD; Mala Joneja, MEd, MD; Anna Bona, MD
Editor: Sreeja Natesan, MD

A Case

Julia is a resident in Internal Medicine covering the clinical teaching unit in July of her first year.

After a busy Monday night on-call covering the inpatient teams, she was happy when she looked back and realized that she was able to problem-solve and appropriately treat various patients who needed attention. She was especially glad that she effectively arranged the transfer of a patient with COPD to the Intensive Care Unit (ICU), and successfully talked one patient out of leaving against medical advice (AMA), in addition to dealing with all of the other calls and pages overnight. 

She met the daytime team on Tuesday morning and gave her signout to the senior resident, Lisa, listing the main issues that came up. Remembering the final months of medical school when a highly-respected ICU attending gave a mandatory lecture on the key components of a handing over patients during sign out, Julia focused on trying to give the oncoming resident a good transition of care.

On Wednesday, Lisa ran into Julia after a lecture and mentioned that, on Tuesday morning, the daytime team was unable to send Mrs. Smith, a woman with newly diagnosed metastatic breast cancer, for her planned interventional radiology procedure. Julia had started the patient on heparin therapy overnight for a new pulmonary embolism and had not informed the day-team. Julia remembered the case, and was horrified to realize that she had forgotten to communicate this in the sign out. 

Though Lisa provided this feedback in a very kind senior-to-junior resident teaching manner, Julia felt that she had let down the day-team by neglecting to convey this particularly important detail during the transition of care. As she reflected on the sign out list, she recalled feeling overwhelmed with all of the issues that had occurred during her shift, including the ICU transfer and the patient who was going to leave AMA. 

In October of the same academic year, Julia was scheduled to begin an 8-week rotation in the ICU as a junior resident. Not only was she very nervous to begin a rotation where she would be responsible for making multiple critical decisions on shift, but she was also more afraid that she would make another error during the handoff and that a patient would have a poor outcome caused by her oversight. Over the past few months, she had independently researched transition of care and tried different techniques, but she still felt unprepared as October loomed closer. 

Background

The person credited with the establishment of sociocultural learning theory is Russian psychologist, Lev Vygotsky, in the 1920s. This theory was contrary to the popular views of the time that centered around the concept of knowledge acquisition primarily depending upon the individual traits of a learner.¹ Vygotsky is most well known for his descriptions of the ZPD and the importance of a “more knowledgeable other” in a child’s advancement. In addition to being known for establishing sociocultural learning theory, Vygotsky also made significant contributions to educators’ understanding of the impact of language on learning.^1-2

After Vygotsky’s untimely death from tuberculosis in 1934, there was a long period of time in which his work was not widely known and was heavily edited due to barriers of language and political discourse.^1,3

In 1976, Jerome Bruner and his colleagues expanded on Vygotsky’s theory by describing scaffolding, a term used to characterize the aid a “more knowledgeable other” contributes to the development of learners, by supporting students until they are ready to work on their own.^4-5 Scaffolding has been applied to adult learning theory in many fields, and more recently, some have proposed the usage of technological tools to perform scaffolding functions.⁵

In the 1990s, Lave and Wenger worked to describe Situated Learning Theory (SLT) in which learners progress through legitimate peripheral participation in a community of practice (CoP).⁶ A CoP is an environment in which multiple participants work towards a common goal by sharing information and learning from each other as they interact.⁷ Novice learners are typically included at the periphery of a CoP through intentional involvement with the guidance of central, more experienced participants, gradually increasing their level of participation as they gain comprehension and familiarity. Today, a community of practice may be utilized in the workplace, in the classroom through team-based learning, or in an online setting to further knowledge acquisition and productivity.^6-8

Despite the increasing presence in literature describing sociocultural learning theory in education over the past 30 years, medical educators have tended to focus on learners as individuals and did not strongly consider the effects of the learning environment and social interactions on medical trainees. However, more recently, instructors in the field of medical education have begun to realize the importance of team dynamics and interprofessional development in the learner experience and have started integrating these theories into their practice.^9-11

Modern takes on this Theory

Modern takes on Sociocultural Learning Theory include Cultural-Historical Activity Theory in simulation education and the incorporation of the Zone of Proximal Development in surgical education.

Cultural-Historical Activity Theory provides a framework to evaluate simulation training by analyzing learners’ relationships and the connections between thoughts and emotions related to their actions.¹² Key points Yrjö Engeström emphasizes in this theory are that:

1. learning is accomplished as a group working towards a common goal,
2. context has many elements of influence, and
3. that measured outcomes have multifaceted perspectives.²  

Simulation is a social activity, and incorporates a group of learners, which differs from the longstanding individualized theories typically applied in medical education.¹⁰ The use of simulation education has increased over the past decade, and its utility in team training has been recognized.¹³  The evaluation of simulation education using this model includes having a collaborative inquiry, with cycles of action and reflection which can be related to learning objectives, a simulation, and debriefing respectively.¹⁰   

An example of an application of this theory is an interprofessional cardiac arrest simulation. The overarching objectives (inquiry) may be optimizing communication, collaboration, and developing a shared mental model with successful resuscitation management.¹⁴ The cardiac arrest simulation (cycle of action) has influences from each individual’s prior experiences and knowledge, the physical setting and location, and the patient’s characteristics. Each of the participating learners will have differing perspectives, from acting as team leader, to performing airway management, and to deciding on medication administration. Debriefing (reflection) will help to determine the connection between learners’ perspectives and their actions.

In keeping with the principles of sociocultural learning theory, simulation can provide an ideal environment to create a ZPD for specific skills that is appropriate for learners to repeatedly practice skills.¹¹ Various scaffolding supports could include teachers, checklists, education videos, etc. that are added as needs, and then removed as learners progress. 

As medical educators continue to recognize the need to emphasize teamwork and communication, Team-Based learning may be another useful framework where peers and near-peers can determine the ZPD and create a CoP.⁸

Additionally, surgical education has recognized the four stages of the ZPD as a useful educational model. Stage I includes assistance from more capable others, using modeling or guidelines. As the learner progresses, the support or scaffolding can be decreased, referred to as Bruner’s Handover Principle. Utilizing feedback and frequent, clear goals can aid in this progression. In Stage II, the learner is self-assisted internally, before progressing to Stage III, independent practice with automatized performance. Stage IV results in deautomization and regression to the ZPD. The key point is that all levels of surgeons can benefit from assessment and feedback, particularly for rarely performed surgeries at high risk of deautomization.^15-16 Future potential for medical education includes integrating these stages to help develop and maintain not only trainees’, but also experienced providers’ competency, thus extending the relevance of modern takes on SCT to continuing professional development.  

Other Examples of Where this Theory Might Apply

Additional applications of this theory include online and virtual education. There is potential for virtual educational programs to provide scaffolding, with both assistance and tools to help learners accomplish tasks that they could not accomplish independently. This assistance can be in the form of prompts, videos, checklists, or explanation feedback.⁵ An example of such an educational program would be an online module on teaching how to give a high-quality signout for transition of care, including a demonstration video with modeling of an example and a detailed checklist. 

Virtual communities provide a ripe opportunity for growth both in the classroom and clinical setting. In Australia, a high school utilized a “work progress” shared electronic writing platform that allowed the teacher and fellow classmates to provide written feedback for the learner’s research project.¹² This shared format allowed for numerous educational social interactions for the construction of knowledge. ALiEM and CanadiEM created CoP to aid in scholars exchanging knowledge and mentorship.^7,17 A CoP can be created in various clinical or academic environments to promote shared, group learning and a CoP can be a part of either medical school or residency training to help accomplish educational goals. In addition, a CoP could contribute to Team Based Learning, helping learners identify and progress through their ZPD stages together until automaticity is achieved.   

Limitations of this Theory

The primary limitation to an in-depth understanding of Vygotsky’s theories is the incomplete nature of his work due to his untimely death. In addition, there have been multiple translations of his original thoughts from Russian and it is thought that some details may be widely misinterpreted today.^1,3

Learning environments influenced by sociocultural learning theory often have many learners interacting and speaking in conjunction. This may cause undue stress for learners who have auditory sensitivities or difficulty with social interactions. Instructors must remain mindful of the individual needs of their students and be sensitive to their potential discomfort in this setting, providing options for less stimulating surroundings if necessary. 

Every learner has a different ZPD. Sociocultural learning requires the instructor or “more knowledgeable other” to be attuned to each students’ current level of development and potential for knowledge expansion, individualizing feedback to promote an optimal level of advancement for all.  

Returning to the case…

Julia began the first week of her ICU rotation with the experience of a few inpatient medicine rotations now comfortably behind her. On the first day of the ICU rotation, the attending physician, Dr. Rogers, suggested that Julia sit in on the morning signout meeting between attendings to observe the transition of care before going to see her assigned patients. 

Julia noticed that the overnight ICU attending who was signing out had a clear and systematic approach to reporting to the daytime attending, and the same system was employed by each ICU physician signing out every morning. She made note of the acronyms used, keeping them in the notes section of her phone, and she also observed the amount of detail given for each case. She enjoyed the back-and-forth discussions during the signout, finding this to be an interesting learning experience as well. 

At the end of the first two weeks, Julia approached Dr. Rogers to ask what training the ICU fellows receive around transitions of care. Dr. Rogers explained that signout was a key skill of ICU physicians and part of the practice culture, and they prepared fellows for this with frequent in-person simulation scenarios and regular direct observation by attending staff with feedback. She directed Julia to online videos that were used for the ICU training program and asked Julia why she was interested in transitions of care in particular. 

With remorse, Julia silently recollected the case of Mrs. S. from July and the omitted detail of the new heparin drip at the signout.

Julia decided to share that she found the structured education of proper signout effective to improve provider communication and, therefore, improve patient safety and care. For her, the ICU learning environment was instrumental in developing her skills in transitioning care through observing and interacting with the attending physicians as they demonstrated proficiency in effective signout. By the end of the assignment, Julia was pleased to realize that she had made no significant errors during her handoffs and she felt much more comfortable advancing to her next clinical rotation. 

Afterwards, she made a suggestion to her program leadership that the next year’s interns should have a simulation session regarding appropriate signout techniques during their orientation, monitored by experienced providers.  

References

1. Polly D, Allman B, Casto A, Norwood J. Sociocultural perspectives of learning. In West RE, ed. Foundations of Learning and Instructional Design Technology. Pressbooks 2017. Available at: https://lidtfoundations.pressbooks.com/chapter/sociocultural-learning/
2. Yardley S, Teunissen PW,  Dornan T. Experiential learning: AMEE Guide No. 63, Medical Teacher. 2012;34(2): e102-e115. doi: 10.3109/0142159X.2012.650741
3. Vasileva O, Balyasnikova N. (Re)Introducing Vygotsky’s thought: From historical overview to contemporary psychology. Front Psychol. 2019;10(1515). doi:10.3389/fpsyg.2019.01515
4. Coombs NM. Educational scaffolding: Back to basics for nursing education in the 21st century. Nurse Education Today. 2018;68:198-200. doi:10.1016/j.nedt.2018.06.007
5. Reiser BJ. Scaffolding complex learning: The mechanisms of structuring and problematizing student work. Journal of the Learning Sciences. 2004;13(3):273-304. doi:10.1207/s15327809jls1303_2
6. O’Brien BC, Battista A. Situated learning theory in health professions education research: A scoping review. Advances in Health Sciences Education. 2019. doi:10.1007/s10459-019-09900-w
7. Ting DK, Thoma B, Luckett-Gatopoulos S, Thomas A, Syed S, Bravo M, et al. CanadiEM: Accessing a virtual community of practice to create a Canadian national medical education institution. Society for Academic Emergency Medicine. 2019;3(1):86-91. doi: 10.1002/aet2.10199
8. Burgess A, Haq I, Bleasel J, Roberts C, Sarsia R, Radna N, et al. Team-based learning (TBL): A community of practice. BMC Med Educ. 2019;19(369). doi:10.1186/s12909-019-1795-4
9. Hodges BD, Kuper A. Theory and practice in the design and conduct of graduate medical education. Academic Medicine. 2012;87(1):25-33. doi:10.1097/acm.0b013e318238e069
10. 10.Bleakley, A. Broadening conceptions of learning in medical education: The message from teamworking. Medical education. 2006;40(2):150-157. doi:10.1111/j.1365-2929.2005.02371.x. 
11. McInerney P, Green-Thompson LP. Theories of learning and teaching methods used in postgraduate education in the health sciences: a scoping review. JBI Evidence Synthesis. 2020;18(1):1‐29. doi:10.11124/JBISRIR-D-18-00022.
12. Verenikina I. Vygotsky in Twenty-First-Century research. Paper presented at the Proceedings of the World Conference in Educational Multimedia, Hypermedia and Telecommunications, Chesapeake, VA. https://ro.uow.edu.au/cgi/viewcontent.cgi?article=2337&context=edupapers. Published 2010. Accessed May 28, 2020.
13. Stocker M, Burmester M, Allen M. Optimisation of simulated team training through the application of learning theories: a debate for a conceptual framework. BMC Medical Education. 2014;14(69). https://doi.org/10.1186/1472-6920-14-69.
14. Decker S, Anderson M, Boese T, et al. Standards of Best Practice: Simulation Standard VIII: Simulation-Enhanced Interprofessional Education (Sim-IPE). Clinical Simulation in Nursing. 2015;11(6):293-297. https://doi.org/10.1016/j.ecns.2015.03.010.
15. Bruce D. Assisted Performance and the Zone of Proximal Development (ZPD); a Potential Framework for Providing Surgical Education. Australian Journal of Educational & Developmental Psychology. 2003;3:48-58.
16. Ahmed M. Simulation-based training of procedural skills: application and integration of educational theories. Urology News. 2017;22(1). https://www.urologynews.uk.com/features/features/post/simulation-based-training-of-procedural-skills-application-and-integration-of-educational-theories. Published November 1, 2017. Accessed My 20, 2020. 
17. Chan TM, Gottlieb M, Sherbino J, et al. The ALiEM Faculty Incubator: A Novel Online Approach to Faculty Development in Education Scholarship. Academic Medicine. 2018;93(10):1497‐1502. doi:10.1097/ACM.0000000000002309.