Section 1: Defining student engagement
"Generally speaking, the concept of 'student engagement' is predicated on the belief that learning improves when students are inquisitive, interested, or inspired."1 Several types of engagement exist — behavioral, emotional, and cognitive among them — and have an impact on whether or not students are successfully learning. Conversely, of course, if learners are bored, distracted, or disaffected — in other words, disengaged — learning will suffer.
Great Schools Partnership defines student engagement as “the degree of attention, curiosity, interest, optimism, and passion that students show when they are learning or being taught.”2 The National Association of Independent Schools (NAIS) simplifies the definition to “meaningful student involvement throughout the learning environment.”3
Each definition boils down to the amount of interest and involvement a student experiences during learning. The more invested the student is in learning, the more likely she is to understand and retain the information.
Engagement looks different based on the topic, class, and individual. Classroom engagement occurs on multiple levels, and addressing each level can help instructors sustain students' engagement. The three types of engagement that we will address here are:
- Relational Engagement: this is the positive or negative reaction a student experiences when interacting with an educator, occupying a learning environment, or receiving course curricula.
- Behavioral Engagement: the actions a student takes during learning that reflect participation and compliance.
- Cognitive Engagement: the internal efforts by students to understand and retain curricula through engagement in academic tasks.4
Most efforts to promote engagement focus on behavioral engagement. It’s the type of engagement educators can see. For example, a student is not looking at her instructor during a lesson, so her behavior reflects disengagement. The instructor can try to refocus her by calling her attention back to the lesson.
If the student from the above example is simply distracted, a short-term refocusing may be all that is necessary. If she continues to lose focus, she might be emotionally disengaged, Emotional Disengagement falls under relational engagement, and this type of engagement is viewed by experts as the most relevant to classroom management that promotes optimal engagement.5
If a disengaged student isn’t experiencing a negative emotional reaction to the curricula, their cognitive engagement can expose the root cause of their inattention. A student may simply be struggling and in need of tutoring or attention. If they aren’t attempting to learn, a frank conversation may be necessary.
Learning in the simulation setting relies on hands-on experience. Always functioning in the role of observer isn’t enough to establish proficiency. As healthcare education focuses more on scenario-based training, students who fail to go all-in will fall farther behind.
Section 2: Engaging a New Generation of Learner
What is Generation Z?
Generation Z, also referred to as post-Millennials, is the subject of research, scrutiny, and sometimes criticism because it represents such a large portion of the population. Statista reported the following population sizes for each generation in the United States in 2017:
- Generation Z (born 1997- present): 86.43 million
- The Millennial Generation (born 1981-1996): 71.8 million
- Generation X (born 1965-1980): 65.71 million
- The Baby Boomer Generation (born 1946-1964): 73.47 million
Generation Z outnumbers Millennials and even the Baby Boomers. The oldest members of Generation Z are currently 22, making them the focus of post-secondary educators.6 In addition, Generation Z is enrolling in college at a higher rate than Millennials were at the same ages.7
Generation Z displays a few key trends in the United States. TThey are the most educated generation, with high school drop-out rates being much lower than generations before them. Post-Millennial parents are most likely to be college-educated parents. Gen Z are also more diverse than any generation before. Pew Research Center reported in 2018 only 52 percent of post-Millennials age 6 to 21 are non-Hispanic whites.8
Technology plays a large role in the lives of Generation Z. Rather than viewing technology as a tool, they see it as a normal part of life. They’ve been surrounded by it since birth, and as such, they are digital natives. They are “early mobile adopters,… expect ubiquitous connectivity, seek on-demand content, and prioritize gaming.”9
How to Engage Generation Z
Teaching Generation Z, like any group, will present unique challenges. Some obstacles educators might experience include:
- Dependence on technology
- Limited focus
- Frustrations with being instructed
- Non-linear thinking
- Easily influenced
However, despite what instructors may perceive as challenges, Generation Z displays certain strengths. They are invested in receiving and participating in meaningful education. Generation Z is highly literate in technology and has strong multitasking skills.
Educators can engage post-Millennials in the following ways:
- Incorporate technology: Modern students have high technological literacy. Technology can be incorporated in the classroom to drive student’s self-learning.
- Build a social network: Social networking is a way of life now. It can be used to reinforce learning by engaging students outside of class. Creating an open forum allows students to interact with one another while completing homework and ask questions of faculty.
- Explain “Why?”: Connect what students are learning to the larger context. What’s the bigger picture? Why do they need to know each lesson?
- Be brief: Screens are everywhere, constantly inundating us with information. Post-Millennials were born in this environment, which can limit their ability to focus. They learn best in brief installments.
- Use visuals: Learning that engages multiple learning types (auditory, visual, kinetic) can enhance learning. Modern students skew more visual. Incorporating simple graphics can increase learning and retention.
- Encourage participation: Teaching can’t help a student who doesn’t internalize the information. When they participate, students prove they are absorbing information. Require students to answer questions, offer their own examples, and discuss their challenges during class.10
Section 3: Identifying disengagement
In the Classroom
Disengagement in the classroom can be detrimental to student retention and learning. Class lectures provide the framework of knowledge to be used in simulations and clinical rotations. A student who fails to engage in class could hinder the rest of their learning experience and stunt their professional growth and effectiveness.
Classroom educators have the advantage of constant exposure to their students. In scenarios, an educator’s focus can be split among multiple groups. During clinicals, educators rarely get a quiet moment to discuss student effectiveness. Classroom educators must use this early exposure to identify signs of disengagement and intervene.
What does classroom disengagement look like?
Early signs of behavioral disengagement might include any or all of the following:
- Interaction: The most obvious form of disengagement is in students’ lack of interaction with educators and other students. They may avoid answering questions during class. During breakout discussions, they’ll be quiet and withdrawn, allowing their group members to steer the conversation. They usually won’t ask questions or offer signs that they need help.
- Reliance: Classes contain a mix of students. Some are ambitious and eager to participate. Disengaged students may rely on these peers in group work and discussions. If called on directly, they may simply say, "I agree with what's been said."
- Body language: Some students don’t have to speak to reveal their engagement level. When the class is asked to participate, some will appear visibly uncomfortable. They may avoid eye contact with their instructor or shrink in their seat. Even the seat they choose can reflect their comfort. Are they sitting in the front or back of the room? Do they remain near the door?
In the Simulation Lab
Simulation is an important part of modern healthcare education. According to a 2010 report by the National Institutes of Health (NIH), “Learners who go through simulation do perform better on subsequent simulated tests and tasks.” Because of the benefits of simulation education in health care, more institutions that provide healthcare education, from nursing to EMS to medical school, are turning to simulation-based learning. 11
However, in a survey by Pocket Nurse® 30 percent of 555 healthcare educators who responded noted that two of their biggest challenges are student engagement and retention.12 Disengaged students limit their learning and cost engaged students valuable time and resources in the lab. Hands-on learning, by definition, requires contact.
What does simulation disengagement look like?
Students in simulation scenarios can show disengagement at any stage of the simulation: at prebriefing/preparation activities, during the scenario, and during debriefing. Disengagement in the simulation lab is similar to other types of disengagement, but it does produce some unique signals:
- Distance: Disengaged students will physically distance themselves from the scenario. They prefer to watch while their peers participate. They may offer to be the "runner" during the scenario, going to fetch supplies, medications, and other equipment as needs arise. During debrief, the disengaged student may seat himself far away from the facilitator, and be quiet during discussion.
- Tailored engagement: Students will volunteer for easy tasks to avoid full participation. For example, they may volunteer to take notes during the simulation. This keeps them from opening themselves to making mistakes. Be cautious when addressing this type of engagement. Some students learn well through observation. If a student continues to volunteer as notetaker, ask them simple questions about the simulation’s lesson. If they cannot answer, they may be disengaged.
- Body language: Physical manifestations of disengagement vary from those in the classroom. Students can appear physically anxious or uncomfortable. Discomfort can be apparent on the student’s face or body. Uncomfortable students may fidget, rubbing at their faces or necks, or they will take a step back and cross their arms.
Spotlight: Engage students’ sense of smell
Smell, more than any other sense, can instantly invoke a long-forgotten memory. The scent of freshly baked cookies can take you back to your grandmother’s kitchen; newly mown grass can remind you of the summer you worked in landscaping.
The NIH reports a close connection to the olfactory pathways responsible for our sense of smell and the sections of the brain responsible for emotion and memory. Research reveals that the olfactory system, while simple compared to other sensory systems, has a “direct access to the emotional centers of the brain.” As such, our sense of smell is uniquely designed for emotional learning and memory. 1
Educators can take advantage of this connection by using students’ sense of smell in learning. A good guideline for creating immersive simulation scenarios is to stimulate at least three senses. The more students learn to associate certain smells, sounds, and sights to a specific situation in a simulation, the more easily they will be able to recall their training when they encounter that situation in the field. 2
Experts in simulation encourage instructors to take advantage of all the resources available to create a scene that truly stimulates the senses. It’s nearly impossible for a student to “pretend” that certain stimuli are present in the simulation when they are not. Incorporate synthetic smells into your simulation with Pocket Nurse’s highly concentrated vomit, fecal, urine, and burnt flesh smells.
Section 4: Causes of disengagement
Why are students disengaged? It’s a complicated question with a variety of answers. Educators must evaluate disengagement on an individual basis. When reviewing possible reasons, there are a few they should consider.
First, psychological safety in the classroom is crucial for student engagement. According to a report by the University of California Los Angeles (UCLA), “…disengagement from classroom learning is associated with threats to feelings of competence, self-determination, and/or relatedness to valued others.” When students worry about their teachers’ or peers’ opinions, they tend to disengage.13
Students lacking in confidence are often afraid of providing incorrect information or failing in front of their peers. Mistakes won't harm simulated participants in the simulated setting, but they can seem embarrassing. 14
Second, students can also disengage due to a lack of preparedness. When they aren’t prepared, students will naturally avoid displaying that fact by avoiding attention entirely. Not being prepared can lead to lack of knowledge. Students should be made aware if a simulation is being used to highlight gaps in their knowledge. They shouldn’t be embarrassed if they don’t know everything.
Finally, disengagement can be the result of outside factors. Students might have stress in their home or social lives. Perhaps they aren’t interested in the course material and should consider switching to another class. They may even be physically ill. Outside factors are not always visible, making it difficult for educators to evaluate if they are the cause of a student's disengagement.
"When I start my class, I want to know why students enrolled. Are they required to take the class? What do they want to get out of it? Whatever an instructor does in the first 15 minutes of class, that's what students remember. Try to engage them in that first 15 minutes.
"Once I identify disengagement, I try to solve it by telling stories, explaining why lessons are important, engaging students' emotions, and changing lessons to increase engagement when students wander."
Catherine Recznik, Ph.D, RN, CEN, CPEN
Assistant Professor of Nursing
Franciscan University of Steubenville
Spotlight: Curriculum for emotional engagement
Introducing Patient Death in Simulation Scenarios
A current issue in the field of simulation education is how to best prepare students for a patient's death -- and whether it's even appropriate to do so within a simulation.
Dr. Dorian Williams, Medical director of the Shaw Center for STEPS (Simulation Training and Education for Patient Safety) at West Virginia University recently presented on "Difficult Simulation Situations: To Die or Not to Die."1 He looked at the outcome from several randomized trials where death was introduced in a simulation scenario. His summary is as follows:
- Evidence exists to support the hypothesis that “learner exposure to patient death from errors during learning result in better long-term performance for the majority.” (Emphasis added.)
- The emotional impact of patient death may result in difficulty in processing information and reduced learning; in some cases, the negative impacts have long-term consequences.
- The impact on learners differs significantly if the death is planned as opposed to if the death is unexpected and the result of student action or inaction.
- Debriefing is essential when the death is unexpected.
Although the overall consensus is still inconclusive from the studies Dr. Williams examined, instructors can agree that the emotional state and level of preparedness of learners need to be considered when attempting to introduce death into simulation scenarios.
The Last 5 Minutes
One of the hardest things for healthcare workers is learning to deal with death. Students connect easily with death-focused curricula. In their presentation, “Enhancing your program with simulation," Richard Antinone, RN, MSN, CEN, and Catherine Recznik, RN, MSN, CEN, CPEN shared their “Last 5 Minutes” scenario.2
At Franciscan University, last med-surg simulation (in a given semester) is a simulation focused on end-of-life care. In the first half of the simulation, students have the chance to care for a patient with a respiratory condition, with a mid-point “debrief” focused on the assessment and management of respiratory distress and respiratory failure. Following this, students work through a death and dying scenario aimed at teaching students empathy, compassion, and end-of-life care.
In the end-of-life care scenario, students must inform patients that their death is impending and do what they can to comfort them and their family.
Many students find it troubling or uncomfortable being unable to save these simulated patients. Healthcare students often have an instinct to help. When faced with the simulation, some cry, others pray. Many of them struggle to use terms like “death” and “dying,” leading to miscommunications.
Besides being an excellent form of engagement, this lesson is important in informing the behavior of future healthcare professionals.
Section 5: Solutions to disengagement
An educator’s job is challenging and complex. Healthcare educators in higher education are expected to be more than instructors. They are expected to maintain their credentials, learn new and emerging techniques and technology, constantly refine their curriculum, and coordinate clinical sites. Educators in smaller programs can even be held responsible for resource acquisition, storage maintenance, and new faculty training. And of course they are preparing students for standardized tests and to excel in their future careers!
It can be difficult to review students’ learning goals or personalize learning experiences for different learning needs. Still, addressing disengagement remains a priority.
How to address disengagement
There are several ways to combat disengagement. Solutions will vary in effectiveness depending on the root cause of the specific disengagement.
- Explain learning goals. Certain truths apply to nearly every class. Healthcare education can’t discuss every eventuality. Human ailments are too varied and complex. Instead, instructors encourage their students to think critically. Explaining this can help students see the bigger picture. Once students understand how best to use their instructors, they may be more likely and better able to engage. It might relieve students who feel overburdened by the breadth of their studies to know they’ll graduate armed with the tools to solve complex challenges.
- Don’t help. It may sound counterintuitive, but helping students can create a dependency. For example, an instructor poses a question to his or her class. It may be difficult to resist jumping in to answer the question on the students’ behalf. Educators are naturally inclined to help, but an uncomfortable silence may support learning better than a quick answer. Students may feel pressure when they’re unprepared for a scenario. This discomfort may encourage students to be better prepared next time.
- Call on disengaged students. The simplest solutions are sometimes the best. Calling on a disengaged student can force him or her to join the conversation in the short-term. Specifically asking anxious students to participate can reveal their questions and reservations as well as make them more comfortable with engaging in the future.
- Let students learn from each other. Sometimes students are more comfortable with one another than they are with faculty. Incorporate small group discussions and activities. Students uncomfortable with discussing their confusions with the full class might be more willing to ask a small number of students. When a student asks a valid question, return it to the class. Learn how common the question is and offer the opportunity for students to work through the question.
- Individual conversations. Some students will fail to engage even after their instructor has attempted the above tips. Instructors should be prepared to pull students aside and speak to them privately about their performance. Sometimes students just need to hear their professors are concerned to change. This one-on-one time may also provide an opportunity for students to discuss outside stressors that could be impacting engagement and performance.
The key to re-engaging students and keeping them focused is to track progress, solicit student and faculty feedback, and use resources, such as the Seattle University Simulation Evaluation Tool, for tracking metrics and evaluate student performance.16
Student disengagement may seem like the students' problem, but when faculty and students can partner to make effective, lasting learning a priority in their program, better professionals emerge — and with them, better future patient care outcomes.
- Great Schools Partnership, Glossary of Education Reform, “Student Engagement,” https://www.edglossary.org/student-engagement/.
- Martin, J. and Torres, A., “User’s Guide and Toolkit for the Surveys of Student Engagement: The High School Survey of Student Engagement (HSSSE) and the Middle Grades Survey of Student Engagement (MGSSE).” National Association of Independent Schools (NAIS.) https://www.nais.org/Articles/Documents/Member/2016%20HSSSE%20Chapter-1.pdf
- “What Does It Mean for Students to Be Engaged?” https://www.corwin.com/sites/default/files/upm-binaries/50258_Davis___An_Interpersonal_Approach_to_Classroom_Management_CH1.pdf
- “U.S. Population by Generation,” Statistics, Statista.com https://www.statista.com/statistics/797321/us-population-by-generation/
- Fry, R. and Parker, K. “Early Benchmarks Show ‘Post-Millennials’ on Track to be Most Diverse, Best Educated Generation Yet,” Social & Demographic Trends, Pew Research Center, Nov. 15, 2018. http://www.pewsocialtrends.org/2018/11/15/early-benchmarks-show-post-millennials-on-track-to-be-most-diverse-best-educated-generation-yet/
- Jenkins, Ryan. “How Generation Z Uses Technology and Social Media,” https://blog.ryan-jenkins.com/how-generation-z-uses-technology-and-social-media
- Wondergem, Karen. “Here Comes Z: Strategies to Engage a New Generation of College Students,” eLearning Industry, https://elearningindustry.com/engage-a-new-generation-of-college-students-strategies
- Lateef, Fatimah, “Simulation-based learning: Just like the real thing,” Journal of Emergencies, Trauma, and Shock, NCBI. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2966567/
- Bethards, Melody, “Identifying and Addressing Disengagement in the Simulation Lab,” SimTalk Blog, http://blog.simtalkblog.com/blog/identifying-and-addressing-disengagement-in-the-simulation-lab
- “School Engagement, Disengagement, Learning Supports, and School Climate,” A Resource Aid Packet, UCLA Center. http://smhp.psych.ucla.edu/pdfdocs/schooleng.pdf
- Bethards, SimTalk Blog.
- Mikasa, A.W., Cicero, T.F., and Adamson, K.A. (2012). Outcome-based evaluation tool to evaluate student performance in high-fidelity simulation. Clinical Simulation in Nursing, 9(9), e361-e367.
Content written by Evan Stiger, Marketing Coordinator; edited by Dawn Mangine, Content Manager. Thanks to graphic design intern Abbey Valentine for the Pocket Nurse graphics, and Nicki Murff Goedecke for final proofreading.