Based on experiential learning within simulation-based education, TeamSIM is designed for undergraduate medical students. Organized in teams, they are invited to participate and observe each other in simulations of different clinical situation. Guided by an interprofessional clinical faculty with simulation-based instructor training (i.e., nurses, midwifes, physicians, psychologists), student teams reflect on their shared experience in structured team debriefings. They practice essential teamwork skills such as handover communication and speaking up and can experience the translational effects of psychological safety (Pollard and Tombs, 2022; Purdy et al., 2022).

A core pedagogical principle of TeamSIM is single and double-loop learning (Argyris, 2002). Single-loop learning involves learning and refining skills by comparing one’s behavior with practice standards (Argyris, 2002). Here, simulation faculty support learners by teaching and coaching (Fey et al., 2022). Double-loop learning helps learners to identify the frames (i.e., assumptions, beliefs, mental models) that drive their particular behavior (Argyris, 2002). Students may learn that the assumptions they think they hold (i.e., espoused frames, e.g., “teamwork is important”) differ from the assumptions that actually drive their behavior (i.e., actual frames, e.g., actually thinking that “clinical skills are much more important than teamwork skills” and, as a consequence, not engaging in shared pre-briefings to plan their work). Here, simulation faculty supports via facilitation by sharing their observations and points of view and inquiring the students’ point of view (Rudolph et al., 2007, 2008b; Fey et al., 2022).

Single and double-loop learning are represented in SimZones—a system to organize simulation activities based on learners, learning objectives, signal and noise and action, feedback and debriefing. We consider TeamSIM in between SimZone 2 (i.e., acute situational instruction) and 3 (i.e., team and system development, Roussin and Weinstock, 2017). Simulation faculty engages students in coaching and debriefing conversations (Fey et al., 2022). Simulation activities in SimZone 2 and 3 typically involve complex and challenging team tasks and allow learners to deliberately learn from “productive” failure (Sinha and Kapur, 2021). To be able to learn, however, students must feel valued, appreciated and feel that they can share what is on their mind without any repercussions (Edmondson, 1999). This psychological safety is one of TeamSIM’s fundamental pedagogical principles and tracked during TeamSIM’s formative feasibility evaluation (Edmondson, 1999; Rudolph et al., 2014; Johnson et al., 2020; Kolbe et al., 2020; Kostovich et al., 2020; Lackie et al., 2022; Purdy et al., 2022).

In Switzerland, the Joint Commission of the Swiss Medical Schools has issued the Principal Relevant Objectives and Framework for Integrated Learning and Education (PROFILES). They explicitly include the ability to work in healthcare teams as learning objective (Michaud et al., 2016). PROFILES displays three interdependent chapters focusing on General Objectives, Entrustable professional activities (EPAs) and the 265 most common clinical situations. TeamSIM covers learning objectives of the General Objectives, which relate to the different roles of physicians as well as several EPAs, which focus on the main tasks a physician must be able to perform autonomously. Specifically, students examine their roles as medical expert, collaborator, scholar, and professional. The EPAs covered here focus on activities that particularly include teamwork.

TeamSIM includes 12 learning objectives (Figure 1) around recognition and management of knowledge within teams, teaming up, communicating clearly and respectfully, embracing and managing dissent, voice and listening, asking for help and reflexivity (Larson et al., 1998; Christensen et al., 2000; Baron, 2005; Riskin et al., 2015; Schmutz and Eppich, 2017; Hamilton et al., 2019; Riskin et al., 2019; Schwappach et al., 2019; Long et al., 2020; Jones et al., 2021; Kolbe et al., 2021; Lemke et al., 2021; Rudolph et al., 2021; Bamberger and Bamberger, 2022; DiPierro et al., 2022; Taiyi Yan et al., 2022; Vauk et al., 2022; Greilich et al., 2023; Tannenbaum and Greilich, 2023). Additionally, it provides students with the possibility to reflect on the consequences of teamwork for well-being and performance of healthcare professionals as well as for patient care and safety and on implications for their career management.

Guided by an interprofessional clinical faculty, student teams are invited to reflect on their shared experience in structured team debriefings following each simulated case. Experiencing the transformational effects of team psychological safety and practicing teamwork skills in this learning environment is the core of TeamSIM (Roussin et al., 2014; Rudolph et al., 2014; Edmondson and Bransby, 2023). Simulation is a powerful teaching tool and psychological safety and high-quality facilitation are important. We deliberately aimed at establishing a faculty team of experienced simulation educators (rather than student teachers) who are able to guide students respectfully through challenging simulation exercises, debriefings and deal with difficult situations (Grant et al., 2018; Jowsey et al., 2020; Kolbe et al., 2020). They work as physicians, nurses, midwifes, psychologists, and an airline pilot, and typically train their peers rather than students. For TeamSIM, they underwent specific faculty development: the course directors provided detailed orientation on TeamSIM’s learning objectives and curriculum; coordinated objectives and simulation across sessions, scheduled faculty briefing and debriefings, reviewed each of the eight different simulation sessions’s modules, and conveyed their commitment to psychological safety. If possible, faculty conducts debriefs each day over lunch during TeamSIM.

TeamSIM is designed as week-long course and is open to all third-year medical students of a new bachelor on human medicine at ETH Zurich, Switzerland (Weissmann et al., 2020). We invite students to “walk the talk” of teamwork by training teamwork in teams.

We organize students in teams of 11 to 12 people. They remain in their respective team for the full week and participate in eight, in-person, four-hour-simulation sessions representing different clinical situations with varying degrees of complexity (e.g., deteriorating patient in ward; trauma; labor and delivery, Figure 2). Due to logistical reasons, each of the teams follows a slightly different schedule: Team 1 starts with “Teaming up for patient emergency” and ends with “Speak up in teams” (Figure 1) while Team 2 starts with “Managing teamwork and career” and ends with “Teaming up for patient emergency,” etc. Each of the eight 4-hour simulation sessions includes participation in two to three rounds of briefing, simulated case, and debriefing (Figure 2). Students can practice teamwork skills such as leadership from three different perspectives. For example, they can lead the team (1st-person practice), be led by a team member (2nd-person practice) and observe team leadership and followership from the outside (3rd-person practice, Chandler and Torbert, 2003). That is, depending on the case, four to six of the students actively participate while their peers observe them; roles are switched in the subsequent case. The simulated cases are developed by the faculty teaching the respective session (Figure 2).

For the debriefings, the faculty follows the Debriefing with Good Judgment (Rudolph et al., 2007, 2008a) and TeamGAINS (Kolbe et al., 2013) approaches. They use their observations of the students’ actions during the scenarios to provide feedback, inquire their perspectives and discuss different approaches with all team members. During both briefing and debriefing faculty focuses on selected learning objectives. For example, during the session “managing trauma as team,” the faculty introduces and discusses tools for developing the learning objectives #2 (develop & apply strategies for using colleagues’ knowledge and experience in clinical situations), #3 (team up spontaneously and effectively and clarify roles and responsibilities), #10 (realize when they are stretched to their limits with respect to knowledge, skills, attitude), and #11 (apply strategies managing their own subject-specific limits). In addition, the faculty adapts their focus depending on the students’ needs (Cheng et al., 2016). For example, students can re-do or practice certain team actions.

We introduce all students to the course during the formal TeamSIM briefing on Monday morning. Using Zoom (Zoom Video Communications, Inc., San Jose, United States), we discuss expectations, course of events, learning objectives, confidentiality, roles, and logistic details to provide orientation and contribute to a psychologically safe learning environment (Rudolph et al., 2014; Kolbe et al., 2020). We introduce simulation as a teaching tool, reflect on its advantages and limitations, provide recommendations for how to engage in simulation and demonstrate our commitment to respecting students and their perspective. We then invite students into breakout groups in their respective teams to brief themselves and ask them to develop a set of guiding principles for their team (Mathieu and Rapp, 2009). Simulation sessions start Monday afternoon and end Friday morning. TeamSIM ends with a formal TeamSIM debriefing on Friday afternoon when we invite all teams back into Zoom to review TeamSIM. In particular, we ask all student teams to formally debrief themselves based on a structured tool adapted to TeamSIM (Welch-Horan et al., 2021).

Students’ actions are not graded. To pass the course, 90% attendance of the sessions is required.

Of the 94 students participating in TeamSIM, 81 (86.2%) responded to the pre-psychological safety measurement; 45 (47.9%) students completed the post-psychological safety and training reactions survey, 22 (23.4%) of which we could match.

The feasibility evaluation data suggests that students reacted rather positively to participating in activities simulating their future work with each other. They seemed to engage in in-depth examination of their approaches to teamwork. Students’ teamwork skills seemed to improve and their take-aways indicate specific teamwork capabilities. At the end of the course they felt more psychologically safe than at the start. This is an important finding because simulation is an intense teaching tool which involves social risk-taking and, thus, high level of psychological safety (Edmondson and Bransby, 2023). Importantly, the psychological safety that emerges during the simulation may leak into other fields and transfer to clinical practice (Pollard and Tombs, 2022; Purdy et al., 2022). Although our cross-sectional data prevents us from drawing an empirical conclusion, we assume that the reported learnings, improved teamwork skills, and positive reactions are related to the psychologically safe learning culture. While the students’ seemed to have benefited from a learning environment with a high degree of psychological safety, TeamSIM’s week-long intensity seemed to have asked a lot of their perseverance. The emotions reported by students (Figure 4C) suggest that TeamSIM was—beside being “fun” and “joyful”—“overwhelming” and “too much” at points. While this is normal in most complex, simulation-based training (Kolbe and Rudolph, 2018; Keskitalo and Ruokamo, 2021), distributing TeamSIM over a few weeks rather than 1 week might have provided students with more possibilities to digest their learning. However, given the logistical constraints of the medical curriculum and simulation operations, re-building the TeamSIM infrastructure once a week over a few weeks seems daunting.

According to the evaluation data, the students appreciated the teaching, coaching, and facilitation by the interdisciplinary and interprofessional simulation faculty whom they perceived as very engaged and committed. This is to some degree reflected in TeamSIM faculty’s reflections which indicated their ongoing concern about the effectiveness of their educational interventions. In our experience, working with this faculty prior to the course was critical and a necessary ingredient: multiple disciplines and professions went along with multiple approaches to simulation; establishing and maintaining a shared mental model of TeamSIM was important and required various faculty development measures (Cheng et al., 2020; Kolbe et al., 2020; Kostovich et al., 2020; Roze des Ordons et al., 2022).

We experienced three particularly challenges. First, designing, planning, coordinating, and conducting TeamSIM involved effort with respect to course curriculum design and coordination of faculty. In addition to preparing the simulation space, equipment and designing sessions, we needed to recruit and develop the interdisciplinary, interprofessional, clinical faculty. Their availability and willingness to make time and engage in this course in their busy clinical schedules was crucial for its success (Fox et al., 2018).

Second, the complexity of TeamSIM and our deliberate choice to engage an experienced, clinical faculty rather than student peer coaches made this course expensive. Simulation-based education is considered a privilege (Lillekroken, 2020; Mosher et al., 2021). While we think that high-quality education will create long-lasting value, we are aware that finding ways to establish TeamSIM’s sustainability will be challenging. We all did, however, consider the significant investment of time and financial resources also as in investment in the faculty’s educational careers. According the headline reflections, the faculty enjoyed teaching this course.

The third challenge involved a potential mismatch of expectations and experience: while the faculty was highly trained in working with clinicians and aware of the importance of reflecting on practice, students seemed to struggle at points with the expected “amount” of reflection and the difficulties of the cases. This might be a common struggle in simulation-based education (Loo et al., 2018), particularly for students (Jowsey et al., 2020). Meeting their various needs for instruction vs. reflection was challenging, and likely reflects variances in their own personal development (Kerins et al., 2020). More in-depth research on how to support students while they learn to embrace reflecting on their actions will be helpful.

Our feasibility evaluation of TeamSIM revealed limitations. First, we were not able to collect as much evaluation data as planned. We experienced that performing evaluations (i.e., inviting students again and again to complete surveys and headline reflections, rating teamwork behavior of multiple students, each team following a slightly different schedule) added another layer of workload for the faculty and resulted in a lack of interrater reliability data, low response rates, and dropouts which limit the generalizability of our results. We have learned we should more deliberately plan for collecting complex yet important evaluation data (e.g., engaging additional raters, collecting videos and performing the rating based on videos, peer-observation with pre-trained peers, additional evaluation training, etc.). Second, our emphasis on anonymity limited our ability to track individual students’ over time; matching pre and post measures was challenging and in many cases not possible. It also prevented us from conducting multilevel analysis which would have been required because students were nested in teams (Raudenbush and Bryk, 2002). In addition, it prevented us from exploring effect differences between simulation sessions. Third, we did not perform reliability checks for the qualitative data analysis and the α-values of the psychological safety scale were rather low, again limiting the validity of our evaluation findings. Finally, in designing, conducting and evaluating TeamSIM we did not yet factor in potential cultural differences in both students and faculty, nor did we reflect on aspects of equity, gender and inclusion, which are significant limitations and call for change in future TeamSIM iterations (Palaganas et al., 2021; Purdy et al., 2023).

The lessons learned from designing, conducting and evaluating the feasibility of TeamSIM are threefold: first, it takes a team to teach teamwork: a team of interprofessional faculty that embraces simulation-based learning and the psychological safety it requires. Second, both students and faculty appreciated the learning possibilities of simulation-based education, in particular for learning teamwork skills. In line with other research, this project endorses simulation as a teaching method that enables students to experience the complexity of interprofessional teamwork in healthcare and to try out and reflect on different approaches for managing this complexity that work for them. As one of the students remarked, it had helped them to develop “cornerstones in midst of the chaos.” At the same time, this learning can be challenging, intense and overwhelming. Importantly, it should be considered in the context of how psychologically safe the students felt during training. Simulation-based training is a powerful tool; without psychological safety it may significantly impede students’ capacity to learn and develop professional identities (Rudolph et al., 2013; Purdy et al., 2022; Edmondson and Bransby, 2023). Thus, while we think that versions of TeamSIM might be useful for training students of other healthcare professions, we strongly recommend to put high emphasis on establishing and maintaining psychological safety. For example, providing orientation about expectations and learning objectives, engaging learners in a sort of “fiction contract,” caring about logistic details, conveying respect for learners and concern for their psychological safety, and maintaining awareness of the dynamics of psychological safety are helpful actions (Rudolph et al., 2014; Kolbe et al., 2020; Somerville et al., 2023). Third, while teamwork in healthcare may involve a somewhat stable set of skills (Greilich et al., 2023), the way students learn may constantly change with their exposure to an increasingly digital world (Balmaks et al., 2021). The pedagogical format of TeamSIM may need to adapt as well. Finally, evaluating such a complex and intense simulation-based teamwork requires additional preparation. In our view, inspite of the involved effort, simulation-based teamwork trainings such as TeamSIM are a valuable contribution to the teamwork capabilities of our future healthcare workforce.