569044

research-article2015

SAGXXX10.1177/1046878115569044Simulation & GamingClapper

This article is a part of a symposium titled: Theory to Practice in Simulation

Cooperative-Based Learning
and the Zone of Proximal
Development

Simulation & Gaming

111
2015 SAGE Publications
Reprints and permissions:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1046878115569044
sag.sagepub.com

Timothy C. Clapper1

Abstract
Purpose. The purpose of this article is to introduce cooperative-based learning
and Vygotskys zone of proximal development (ZPD) to the simulation
literature as two important mutually supportive learning theories that may
enhance the effectiveness of simulation-based instruction.
Design/Methodology/Approach. A brief literature review of cooperative-based
learning and Vygotskys zone of proximal development (ZPD) is
presented, along with a description of how these two important learning
theories may be applied to improve simulation-based instruction.
Findings. When learning new material or skills, learners sometimes need to be
assisted with moving through the disequilibrium process that can occur when
the new information contrasts with their existing frames of reference or
ways of knowing. Cooperative-based learning and the zone of proximal
development (ZPD) can be used to assist the learner with working through
the disequilibrium process, including accommodating and assimilating
the new skills and information into their own practice.
Limitations/Implications. Gaps in the simulation literature, including ways to
implement both theories into practice, can lead to incomplete or ineffective
simulation-based instruction practices.
Originality/Value. Many organizations have implemented simulation into their
patient safety program, but have not considered how the zone of
proximal development (ZPD) and cooperative-based learning can be
used to improve educational outcomes.
1University

of Colorado Colorado Springs, USA

Corresponding Author:
Timothy C. Clapper, College of Education, University of Colorado Colorado Springs, 1420 Austin Bluffs
Pkwy., Colorado Springs, CO 80918, USA.
Email: timothy.clapper@gmail.com

Downloaded from sag.sagepub.com at UNIV OF PENNSYLVANIA on June 29, 2015

Simulation & Gaming

Keywords
accommodating, adult learners, assimilating, behaviors, brain-based learning, brainbased learning framework for simulation, clinical practice, cooperative-based learning,
disequilibrium, educational outcomes, four-phase lesson plan, frames of reference,
group investigation, health care workers, ineffective simulation-based instruction,
jigsaw, medical error, patient safety, practice, scaffolding, simulation, simulationbased instruction, simulation-based learning, simulation framework, zone of proximal
development (ZPD)

Adult learners and health care workers possess a vast store of accumulated experiences from clinical practice and professional development. These experiences serve as
frames of reference or ways of knowing (Clapper, 2010). Maria Montessori (1949) and
John Dewey (1938) recognized that learners construct their own knowledge by making sense of information via resources provided to them in the learning environment.
As no one acquired or processed the experiences in the same manner (Lederman,
1992), learners enter the learning environment with frames of references that are very
unique to them. Augmenting this uniqueness is the lack of standardization in health
care education and inadequate learning experiences that affect patient safety and learning itself (Barnsteiner, 2011; Clapper, 2013, 2014; Davies & Tales, 2005). As Dewey
posited long ago, a problem that we must face is not a lack of experience, but a lack of
quality experiences. Facilitators and instructional designers must recognize that learners may enter the simulation center with these unique and sometimes deficient frames
of reference.
Simulation is a learning modality that can be used to assess and educate health care
providers by allowing them opportunities to practice and acquire new information in
the pursuit of expertise in their field. Administered correctly, opportunities are provided to the learner to learn and practice with new, evidenced-based information prior
to placing them in a simulated case or scenario (Clapper, 2014). Sometimes, when the
new information contrasts with existing frames of reference or the information is not
associated with anything the learner currently knows, a state of disequilibrium may
occur. This uneasy situation is an internal conflict that occurs as the learners attempt
to juxtapose new information with those frames of reference they brought into the
learning environment (Piaget, 1928, 1973). Often, the learners need to be assisted by
others to work through this conflict to make the new information their own.
This article describes how an understanding of cooperative-based learning and
Vygotskys zone of proximal development (ZPD) may be used as part of a complete
brain-based learning framework for simulation to assist the learner with assimilating
and, ultimately, accommodating new skills and information during simulation-based
instruction. Individually, these two learning theories are well documented in the education literature. However, gaps in the literature within the simulation community,
including ways to implement both of these theories into practice, can contribute to

Downloaded from sag.sagepub.com at UNIV OF PENNSYLVANIA on June 29, 2015

Clapper

inadequate learning experiences. I begin with an overview of each theory and show
how each one complements the other in practice to create better outcomes in simulation-based instruction.

Zone of Proximal Development

Much of Lev Vygotskys (1978) work was focused on developmental methods that
would explain the transformation of elementary processes into complex ones (p. 7).
Although his work may be interpreted superficially and isolated to the development of
children, Vygotsky was clear in applying his reasoning to psychological processes that
included adult learners. One particular concept that came from Vygotskys work was
referred to as the zone of proximal development (ZPD), which describes the difference
between (a) what the learners can learn on their own and (b) what they can learn under
the guidance of a facilitator or others in the learning environment. A ZPD is created in
the learning process when a learner interacts in cooperation with others, but lags
behind in internal developmental (emphasis added) processes (Vygotsky, 1978, p.90).
Providing a brief explanation of the learning process at this point in the article creates
an appreciation for the benefits of a ZPD.

Figure 1. Vygotskys learner transformation process.

Source. Adapted from Vygotsky (1978).

Speech and the use of signs accompany and often precede activity in intellectual
development (Vygotsky, 1978). The learning process begins internally and individually within the learner. As depicted in Figure 1, internal reflection and speech often
facilitate the transformation process that is critical for developing or changing behaviors. In addition, the learner uses tools and resources in the learning environment to
problem-solve. When learners face a challenge, and this may include disequilibrium
that develops from learners conflicts with their current frames of reference, or where
they cannot organize the frames to address the problem (e.g., development), they turn
to the facilitator or other learners. Among other techniques, the facilitator in the ZPD
may use demonstration, discussion, case studies, or real-life examples to assist the

Downloaded from sag.sagepub.com at UNIV OF PENNSYLVANIA on June 29, 2015

Simulation & Gaming

learner with solving the problem. In addition, the facilitator may use a reflection process, described in a bit more detail later in this article, throughout the lesson to assist
those in the ZPD. As noted by Vygotsky, the learners may also imitate others in the
learning environment to assist them with moving past their own limits in the developmental process.
ZPD should not be confused with scaffolding. Scaffolding can be a part of the
activities in the ZPD, but the ZPD does not always involve scaffolding. A facilitator
can assist a learner with comprehension by providing additional resources to support
or scaffold the learning process, while the learner may use other methods, including
imitating others while in the ZPD to move out of the state of disequilibrium.
Cooperative-based learning provides a means for accomplishing both imitation and
scaffolding in the ZPD as we consider ways that we learn with and from each other to
solve problems.

Cooperative-Based Learning
We live in a fast-paced competitive society. In the United States and many other countries, we compare our national education test scores and often attend schools, including medical and nursing programs based on individual test performance. Lecture-filled
classrooms and simulation centers that rely on scenarios and debriefing alone hardly
facilitate the transformation process described in the section on ZPD. Johnson and
Johnson (1975) found that competitive learning environments, among other things,
can lead to mutual dislike, communication problems, and low interaction among learners. Furthermore, individual-focused education may contribute to the lack of teamwork and communication that exists in the health care community (Clapper & Kong,
2012). A breakdown in communication is still recognized as a leading factor in the
high rate of medical error that has not improved much in the last 25 years, especially
during patient handoffs (Clapper, 2013; Clapper & Kong, 2012; Wachter, 2013).
In some form or another, including more than half a century of research, scholars
recognize that we learn with and from one another (Barkley, Cross, & Major, 2005). In
addition, studies show that from infancy through later stages of life, we genetically
empathize and assist others in need (Knafo, 2014). David and Roger Johnson certainly
did not originate cooperative-based learning. However, Johnson and Johnson are best
known for their pioneering, research-based work on learning, working alone, in dyads,
or in groups, that has been field tested in countless classrooms (Johnson, Johnson, &
Smith, 1991). Johnson and Johnson based much of their research and application on
the theory of competition and cooperation brought forward by Morton Deutsch and
Kurt Lewin (Johnson et al., 1991). Cooperative-based learning should not be confused
with group work. Putting learners together and assigning them a task do not guarantee
that learning will occur. Instead, cooperative-based learning techniques (CoLTs) are
those intentional learning activities where learners work together to achieve common
learning objectives (Barkley et al., 2005). The cooperative goal structure recognizes
that a person may be weak in one area, but can be an asset to another group of learners
in a different area (Johnson & Johnson, 1975). Those same experiences and frames of

Downloaded from sag.sagepub.com at UNIV OF PENNSYLVANIA on June 29, 2015

Clapper

Figure 2. Vygotskys ZPD with cooperative-based learning.

Source. Adapted from Vygotsky (1978).
Note. ZPD = zone of proximal development.

reference that each learner brings to the learning environment become group assets
that are useful in the learning process and compliment assistance efforts in the ZPD.
As shown in Figure 2, when a state of disequilibrium may occur, cooperative-based
learning can create the conditions for a zone to develop that allow the struggling
learner to comprehend new information with the assistance of the facilitator or others
in the group.
An abundance of evidence supports the use of cooperative-based learning and its
effects on achievement and motivation (Slavin, 1987). Cooperative learning creates
opportunities for reciprocal teaching where learners teach other members of the group.
For example, Turan, Konan, Kl, zvars, and Sayek (2012) found that students in a
surgery clerkship appreciated the use of cooperative learning because it helped them
to see other perspectives about the learning activity that they might otherwise have
missed. Students in a mental health clerkship, learning adolescent psychopathology
through cooperative learning, gained more knowledge of the topic than students who
learned through lectures (Bahar-Ozvaris, Cetin, Turan, & Peters, 2006). Other
researchers (Tolsgaard, Bjrck, Rasmussen, Gustafsson, & Ringsted, 2013) found that

Downloaded from sag.sagepub.com at UNIV OF PENNSYLVANIA on June 29, 2015

Simulation & Gaming

training with another learner improves the effectiveness and efficiency of the training
session and has positive effects on a clinicians confidence in managing patient cases.
Consistent with the introductory message of this article, clinicians must recognize the
effectiveness of cooperation and working in teams. When learners are engaged with
CoLTs, they are learning team dynamics and conflict resolution while learning the
content (Bahar-Ozvaris et al., 2006; Hromek & Roffey, 2009; Kayes, Kayes, & Kolb,
2005). Whether moving through the ZPD or not, learners use the same process identified earlier in this article, including speech, signs, and reflection (Vygotsky, 1978) to
assist other members of their group with their intellectual development as they
strengthen their own understanding. Although the reasons for applying these theories
to practice are evident, setting up the learning environment for cooperative-based
learning does require additional consideration.

Organizing for CoLT and ZPD

In accordance with good instructional design, cooperative-based instruction used as
part of the complete simulation-based experience (described later in this article) must
be planned ahead of time and involves an active facilitation process. Johnson et al.
(1991) identified five steps in the planning and execution process involved in cooperative-based learning. In addition to these five requirements, the facilitator uses eavesdropping and ongoing reflection to create a ZPD as needed to ensure that learners can
achieve the learning objectives and maximize the learning experience (see Figure 3).
The facilitator must also conduct an assessment of available resources, including room
space, to decide how the groups will be organized.
Furthermore, the size of the group and how the learners will be organized must be
considered. Larger groups can be useful for brainstorming unique and original ideas
(Coskun, 2011), but they can limit individual contribution and participation. Although
Johnson et al. (1991) recognized typical group sizes of 2 to 4 learners, they also
accepted that random group assignment of 6 to 10 have been useful in collaborative
forms of learning (Johnson & Johnson, 1975). In addition to group size, time and
adequate space can be factors. Lesson planning must include additional time so that
learners can reap the benefits of CoLT and ZPD opportunities. For example, students
in a surgery clerkship found cooperative learning very satisfying, but the lack of time
allocated to the project did not allow for adequate organization and engagement of the
cooperative groups (Turan et al., 2012).
Although they do require a bit more time than some other CoLTs, two that I found
extremely beneficial for realizing the advantages of CoLT and ZPD are the jigsaw
(Aronson, Blaney, Stephan, Sikes, & Snapp, 1978) and group-investigation techniques
(see Figure 4). I use topic sheets in conjunction with these two CoLTs, which are evidenced-based summaries of themes critical to a particular subject.
The topic sheets are particularly useful for chunking information, which the brain
prefers when acquiring and sorting new material. The topic sheets also reduce cognitive load on the learner by sorting vast amounts of information that may otherwise be
overwhelming for the learner. The learners are responsible for reading the topic sheets,

Downloaded from sag.sagepub.com at UNIV OF PENNSYLVANIA on June 29, 2015

Clapper

Figure 3. Five steps to cooperative-based learning.

Source. Adapted from Johnson, Johnson, and Smith (1991).

Note. CoLT = cooperative-based learning technique; ZPD = zone of proximal development.

highlighting information, and making notes in the margins prior to reflecting on the
topic(s) with others in their groups. It is often during the open reflection process that
conflict arises between what the learner currently understands and what is written on
the topic sheet. In line with the concept of Vygotskys ZPD, the members of the group
and the facilitator can assist those learners with assimilating the new information.
As noted, the facilitator must place himself or herself in a position where he or she
can observe and eavesdrop on the group conversation and member contributions
(Johnson & Johnson, 1975). The keen facilitator is observant of group dynamics and
the balance of participation (Carrier, 1991). Dominant group members can overwhelm
passive members, and the facilitator must skillfully ensure that all members are free to
express their thoughts. It is important for the person in this role to ask questions that
enable all learners to consider application of the new information. For example, when
teaching the central venous catheter course, I ask about best sites for line placement. I
want the learners to think about the patient situation and not limit themselves to a
favorite site based on personal ease of application.

Downloaded from sag.sagepub.com at UNIV OF PENNSYLVANIA on June 29, 2015

Simulation & Gaming

Figure 4. Jigsaw and group-investigation techniques.

Source. Adapted from Aronson, Blaney, Stephan, Sikes, and Snapp (1978); Barkley, Cross, and Major
(2005); and Johnson, Johnson, and Smith (1991).

Debriefing and Facilitation

For reasons described earlier in this article, we must move away from incomplete
simulation frameworks that provide the learner with a lecture, a simulation experience,
and a debriefing (Clapper, 2014). The four-phase, brain-based learning framework for
simulation described by Clapper (2010, 2014) is advantageous for facilitating cooperative-based learning and assisting learners in the ZPD. This framework consists of
four phases of learning, which mirror the way that the brain acquires and processes
information (Williams & Dunn, 2008). It includes an inquire phase, which creates
situational interest; a gather phase, where new information is introduced; a process
phase that allows the learner an opportunity to practice in a realistic setting; and an
apply phase, useful for assisting learners with confirming the new frames of reference
and transferring the new knowledge to the actual work environment. This simulation
framework recognizes the importance of debriefing in both the reflection-in-action
and reflection-on-action processes. As well-known simulationist and author, Fred
Goodman, insisted, Debriefing is too important to be left until the end of the game
(in Crookall, 2010, p. 908). Debriefing after each phase allows the facilitator to assess

Downloaded from sag.sagepub.com at UNIV OF PENNSYLVANIA on June 29, 2015

Clapper

and further identify/assist those learners who may be in a state of disequilibrium or in

the ZPD prior to moving on to the next phase. Although the debriefing following each
phase is often much briefer than the debriefing that follows the apply phase at the end
of the lesson, it is instrumental for assisting learners with constructing/re-constructing
their frames of reference throughout the learning process. In this simulation framework, the message is clear and addresses our opening concern: Why wait until the end
of a learning experience to assess and possibly miss an opportunity to assist the
learner with developing quality frames of reference and experiences?
The cooperative learning activities occur in the gather phase. Although the learners
may enter the ZPD anywhere in the learning process, it is in the gather phase, where
the learners may be most reticent to completely let go of their older frames of reference that they began with early in the lesson. Debriefing after the gather phase of
learning is especially important as learners (a) discover the learning objectives and (b)
clarify any information that came from materials and discussions in the cooperative
learning activities prior to placing them into the process phase. Individual and group
reflection efforts carry on following the process phase, where members try out the new
information and skills during the patient scenario and, subsequently, enter the apply
phase, where the facilitator uses the debriefing to help the learners affect transfer to
their work environment (Clapper, 2014; Crookall, Oxford, & Saunders, 1987; Williams
& Dunn, 2008).

Conclusion
The world is truly a competitive place, but our learning environments do not have to
be. When learning new information or solving problems, our natural tendencies
include looking at what others are doing or listening to their interpretation of the problem. In addition, our propensity as humans to assist others with solving problems is
complimented by both theories and allows us to support those members of our learning community with altering or building new frames of reference that can affect patient
safety and lead to better outcomes. Cooperative-based learning and an understanding
of the ZPD are valuable tools for the facilitator of simulation-based instruction and
should be considered when preparing lessons as part of a complete and stimulating
framework.
Acknowledgment
Reviewers cause us to reflect critically on our work, including the accuracy and intent of our
message. I am grateful for the anonymous reviewers and their insightful feedback on earlier
drafts of this article. Thank you Iris Cornell, my co-editor for this special symposium, and David
Crookall for your thoughts and encouragement.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.

Downloaded from sag.sagepub.com at UNIV OF PENNSYLVANIA on June 29, 2015

10

Simulation & Gaming

Funding
The author received no financial support for the research, authorship, and/or publication of this
article.

References
Aronson, E., Blaney, N., Stephan, C., Sikes, J., & Snapp, M. (1978). The jigsaw classroom.
Beverly Hills, CA: Sage.
Bahar-Ozvaris, S., Cetin, F. C., Turan, S., & Peters, A. S. (2006). Cooperative learning: A
new application of problem-based learning in mental health training. Medical Teacher, 28,
553-557. doi:10.1080/01421590600834252
Barkley, E. F., Cross, K. P., & Major, C. H. (2005). Collaborative learning techniques. San
Francisco, CA: Jossey-Bass.
Barnsteiner, J. (2011). Teaching the culture of safety. The Online Journal of Issues in Nursing,
16(3), Article 5. doi:10.3912/OJIN.Vol16No03Man05
Carrier, M. (1991). Simulations in English language teaching: A cooperative approach.
Simulation & Gaming, 22, 224-233. doi:10.1177/1046878191222007
Clapper, T. C. (2010). Beyond Knowles: What those conducting simulation need to know
about adult learning theory. Clinical Simulation in Nursing, 6, e7-e14. doi:10.1016/j.
ecns.2009.07.003
Clapper, T. C. (2013). Saturation in training. Patient Safety InSight. Retrieved from http://
www.academia.edu/3712160/Saturation_in_Training_A_lesson_simulation-based_educators_will_need_to_learn_to_make_a_difference_for_patient_safety
Clapper, T. C. (2014). Situational interest and instructional design: A guide for simulation facilitators. Simulation & Gaming, 45, 167-182. doi:10.1177/1046878113518482
Clapper, T. C., & Kong, M. (2012). TeamSTEPPS: The patient safety tool that needs
to be implemented. Clinical Simulation in Nursing, 8(8), e367-e373. doi:10.1016/j.
ecns.2011.03.002
Coskun, H. (2011). The effects of group size, memory instruction, and session length on the
creative performance in electronic brainstorming groups. Educational Sciences: Theory &
Practice, 11, 91-95.
Crookall, D. (2010). Serious games, debriefing, and simulation/gaming as a discipline.
Simulation & Gaming, 41, 898-920. doi:10.1177/1046878110390784
Crookall, D., Oxford, R., & Saunders, D. (1987). Towards a reconceptualization of simulation:
From representation to reality. Simulation/Games for Learning, 17(4), 147-170.
Davies, M.-A., & Tales, H. (2005). Enhancing patient safety through a standardized model of
physiologic monitoring. Healthcare Quarterly, 8, 49-52. doi:10.12927/hcq..17662
Dewey, J. (1938). Experience & education. New York, NY: Touchstone.
Hromek, R., & Roffey, S. (2009). Promoting social and emotional learning with games: Its fun
and we learn things. Simulation & Gaming, 40, 626-644. doi:10.1177/1046878109333793
Johnson, D. W., & Johnson, R. T. (1975). Learning together and alone. Englewood Cliffs, NJ:
Prentice Hall.
Johnson, D. W., Johnson, R. T., & Smith, K. A. (1991). Active learning: Cooperation in the
college classroom. Edina, MN: Interaction Book.
Kayes, A. B., Kayes, D. C., & Kolb, D. A. (2005). Experiential learning in teams. Simulation &
Gaming, 36, 330-354. doi:10.1177/1046878105279012

Downloaded from sag.sagepub.com at UNIV OF PENNSYLVANIA on June 29, 2015

11

Clapper

Knafo, A. (2014, August 14). Are people naturally inclined to cooperate or be selfish?
Scientific American Mind, 25(5), 78. Retrieved from http://www.scientificamerican.com/
article/are-people-naturally-inclined-to-cooperate-or-be-selfish/
Lederman, L. C. (1992). Debriefing: Toward a systematic assessment of theory and practice.
Simulation & Gaming, 23, 145-160. doi:10.1177/1046878192232003
Montessori, M. (1949). The absorbent mind. Madras, India: Theosophical Publishing House.
Piaget, J. (1928). Judgment and reasoning in the child. New York, NY: Harcourt, Brace.
Piaget, J. (1973). Main trends in psychology. London, England: George Allen & Unwin.
Slavin, R. E. (1987). Cooperative learning: Where behavioral and humanistic approaches to
classroom motivation meet. The Elementary School Journal, 88, 29-37.
Tolsgaard, M. G., Bjrck, S., Rasmussen, M. B., Gustafsson, A., & Ringsted, C. (2013).
Improving efficiency of clinical skills training: A randomized trial. The Journal of General
Internal Medicine, 28, 1072-1077. doi:10.1007/s11606-013-2378-4
Turan, S., Konan, A., Kl, Y. A., zvars, S. B., & Sayek, I. (2012). The effect of problem-based learning with cooperative-learning strategies in surgery clerkships. Journal of
Surgical Education, 69, 227-230.
Vygotsky, L. S. (1978). Mind in society: The development of higher psychological processes.
Cambridge, MA: Harvard University Press.
Wachter, R. M. (2013, February 18). Is the patient safety movement in danger of flickering out?
Wachters World. Retrieved from http://community.the-hospitalist.org/2013/02/18/is-thepatient-safety-movement-in-danger-of-flickering-out/
Williams, B. R., & Dunn, S. E. (2008). Brain-compatible learning for the block. Thousand
Oaks, CA: Corwin Press.

Author Biography
Timothy C. Clapper holds a PhD in education and a masters degree in curriculum & instruction with instructional technology graduate certificate. He is an adjunct professor of instructional technology with the University of Colorado Colorado and health care section editor for
Simulation and Gaming. He is also the president of TC Curriculum & Instructional Design,
LLC, devoted to the promotion of brain-based learning in health care simulation and teacher
education. Aside from his work with brain-based learning, he is best known for his work in
TeamSTEPPS and health care simulation, including his Saturation in Training model
described in Why Your TeamSTEPPS Program May Not Be Working, his Conflict Theory
of Medical Errors, described in In Situ and Mobile Simulation: Lessons Learned . . . Authentic
and Resource Intensive, and his approach to educating adult learners described in Beyond
Knowles: What Those Conducting Simulation Need to Know About Adult Learning Theory.
Contact: timothy.clapper@gmail.com.

Downloaded from sag.sagepub.com at UNIV OF PENNSYLVANIA on June 29, 2015