The situational contexts faced by paramedics on a daily basis can be an iterative source of lived experience that is potentially damaging to their mental health and wellbeing (Dixon et al, 2016). From road traffic collisions to terrorist emergencies, it has been reported that 43% of all emergency services employees had taken time off work to deal with mental health issues and will experience a long-term absence from work owing to the impact of post-traumatic stress disorder (PTSD) at some stage of their career trajectory (Mind, 2014). As a direct consequence of this, the concept of psychological resilience is now a topic for debate in affective learning across many allied healthcare professions. This currently constitutes an integral part of all UK paramedic undergraduate/diplomate teaching curricula (Darling-Hammond and Snyder, 2015; Givati et al, 2016). The need to move beyond tokenism in the resultant impact of affective domain learning facilitation is clear. Applying game-playing elements (i.e. gamification) has the potential to catalyse behavioural change and adaptation to different situational contexts (Hetzel-Riggin and Meads, 2016; Dias, 2017).
Social constructionism in education
Historically, the origins of ‘serious play’ as a concept can be found in the seminal work of Piaget (1951) on social constructivism, and the version later developed in Harel and Papert's (1991) Complex Adaptive System Theory. This was evaluated for use by Holland (2006) in terms of application to the contexts of leadership, management and organisational development. LEGO® Serious Play® is a tool designed to enhance innovation and business performance based on research demonstrating that such hands-on, minds-on learning produces a deeper, more meaningful understanding of the world and its possibilities (LEGO, 2018). Its procedural approaches illuminate its capacity to engage students in deeper reflection and collective constructive dialogue.
Play and reflection
Kestly (2014) provided valuable insight into the interpersonal neurology of play, examining the subcortical motivational systems in the brain. LEGO Serious Play powerfully influences the decision-making processes and fundamental behaviours that are regulated in higher brain regions. She also highlighted the notion of ‘thinking with your fingers’, where the physical processes of creation facilitate reflection—an integral part of professional paramedic practice. Since cognitive processes of memory and deep learning stem from the active interrelationship between psychology and neuroscience, the physical body is a key mechanism of interacting physically with the external world (Claxton, 2015).
Creating ‘in the moment’
‘Emergence’ is a term used to represent the connection that happens in right-mode processing of the brain. It attends to what is happening ‘in the moment’ within the emerging flow of new experience. When added to our already active left mode, this is actually the zone of creativity, which is of direct significance to the LEGO Serious Play method. In turn, planning the right mode in the lead is pivotal in allowing what has not yet been thought to emerge via manual construction and gives natural integration of the brain, for something never before imagined. The process of play is temporal and specific to one moment in time.
Social connection
Play also permits the notion of ‘flow’ where emotional escapism, excitement, and social connection can be extended without interruption (Moshman, 2014). Neural change is best supported in instances where participants feel in a shared, collective and emotionally ‘safe’ connection with others (Wilson, 2010). Of huge significance to paramedic practice is the concept that thoughts, meanings and emotions are not just contained within people as metaphorical receptacles—but that they exist between individual human relationships as part of a wider collective vision (Kristiansen and Rasmussen, 2014).
The motivation for adult learners to ‘play’ is driven by affective experiential knowledge, the nature of which they may wish to communicate. Part of aiding them to do this can be achieved by their handling of the individual Lego bricks as they think (Sandoval, 2014; Furness et al, 2016). In instances such as this, the context of playing provides a natural setting in which a voluntary or unconscious therapeutic or cathartic experience can take place (Frick et al, 2013; Gauntlett, 2014).
Potential of LEGO Serious Play in undergraduate education
Resilience in paramedic practice
Engaging critical introspection and reflexivity skills contribute extensively to the development of individual and collective resilience—particularly in professions where the nature of events can potentially lead to the development of PTSD (Bracken-Scally et al, 2016). Schulz et al (2015), followed by Clompus and Albarran (2016), Loo et al (2016), and Michael et al (2016) all reached the conclusion that the evidence base on this subject area to date is sparse and that more research is needed in relation to the long-term mental health implications of being an emergency responder.
Recent terrorist atrocities have highlighted the role of the emergency services and the resultant impact on their health and wellbeing. The media also focused upon this impact, rather than shining a light on those with the responsibility to ensure the equipment and support of a resilient, compassionate and retainable workforce (Hunter and Warren, 2013).
Intrinsic and extrinsic causes of stress
Causative elements of stress can include a number of factors—both intrinsic and extrinsic to the concept of resilience (Eakman et al, 2016). For example, an intrinsic factor could be the individual stress or vulnerability that a person is placed under and their individual capacity to cope. Extrinsically, the degree of control that people have over events in their lives, such as bereavement or loss for example, can have a mammoth impact on their ability to cope with degrees of pressure.
Expectations to march on
With expectations of higher-order thinking skills in the most challenging contextual and situated environments, paramedics are expected to function effectively on an ongoing basis regardless of what they encounter in their daily roles. While witnessing death, unsuccessful resuscitation and severe blood loss are an everyday norm, it is clear that the pedagogic practice underpinning paramedic education, training and continuing professional development (CPD) must equip staff with the prerequisite resilience to cope personally, as well as professionally (Brooks et al, 2016).
Affective domain learning
By deconstructing experiential, situated learnings, which may originate from unfamiliar critical incidents, three-dimensional metaphor-building with the hands provides the basis for the articulation of either an individual or collective narrative or discourse (Heracleous and Jacobs, 2011).
Exploring and reflecting on these issues is one use of LEGO Serious Play in the education of paramedics. The power of expression and articulation of emotion around care is something that ought to be contemplated regularly. Having a medium through which to do this is essential, and LEGO Serious Play is one such route (Cakir, 2008). Other topical approaches to contemplation and reflection are mindfulness and the power of mindsight (human capacity to perceive mind of self and others) (Siegel, 2010). Figure 1 illustrates how Gilbert's (2009) Multi-Modal Compassionate Mind Training can be used to provide a resilience facilitation framework by working with social constructionism (via LEGO Serious Play) in practice. It affords the opportunity for critical expression processes in LEGO Serious Play to incorporate a degree of reflexivity and contemplation of context not afforded by the original model.
Fundamentally, what this diagram shows, is that the central core of resilience that ought to define paramedic practice is locked in outer shells of objectivity that must be accounted for. This highlights that resilience is not only dependent upon objective and formal training, but also the epistemic cognition that paramedics bring to their roles as part of their own experiential life trajectories. LEGO building with the hands enables access to inner emotions and thoughts, as well as their application to practice situations and contexts.
Instructional principles of LEGO Serious Play
Creative expression
By building an object with LEGO bricks (typically described as a social object because it acts as a medium by which students provide their individual stories and perceptions of significant events and contexts), paramedic students can be creative in expressing their thoughts and feelings on certain subjects and areas. The key to active learning in this instance is when the paramedic students may draw and make meaning of their own conclusions from their metaphorical brick-building models (Hinthorne and Reeves, 2015).
Role of the facilitator
The role of the facilitator is a delicate one in this situation. The facilitator's role ought to be as a mediator of creative conceptualisation and experimentation who provides a supportive, rather than a directive, role in the construction of the three-dimensional social objects. For example, a good facilitator might support a student in asking questions about his or her building that might enable the selection of more bricks to articulate his or her story more extensively.
Agenda-setting
Agenda-setting for any session with paramedics would involve the following, each of which will be discussed in more detail in this section:
Framing the challenge
The LEGO Serious Play facilitator presents a relevant challenge to the paramedics or students with no definitively correct answer, but that is clear enough to avoid any ambiguity once the building starts. For example, they might be asked what they think characterises resilience in paramedic practice.
Building with the LEGO bricks
Paramedics would then build their response to what they thought characterised resilience in paramedic practice. Time is taken when the students designate specific meanings to the models they build; and as a result of this, they develop a story that represents how they internalise their response. It is in the narrative storytelling, though, that they convey the new knowledge they construct and, at this point, interpretation by others is neither necessary nor wanted. This new knowledge stems from the active construction process.
Storytelling
The students would then actively apply the meanings that have been designated to their social models (Hinthorne and Schneider, 2012). They would also listen to the stories of others, in order to contextualise and frame their own conceptualisation within this (Gunnarsson et al, 2014).
Meaning-making and shared perspectives
The LEGO facilitator would then encourage the paramedics to think and reflect about the meaningfulness of the experience of using the LEGO as a medium of creative expression, and to articulate their reflections of this.
Discussion and conclusion
Building an active capacity for resilience remains high on the agenda of all health and social care provision. The role of paramedics remains pivotal to this in relation to their capacity to cope in adverse situational contexts.
The impact that LEGO Serious Play has on people's capacity to articulate meaning suggests that this could be applied easily in the context of emergency care services training. Where paramedics can be encouraged to communicate more effectively and confidently, and where they can be intrinsically motivated to think and reflect at a deep level about the situations with which they can potentially be faced, LEGO Serious Play offers one mechanism of engaging imaginations and providing a holistic means of expression that can later be applied in meaningful practice in the context of coping strategies. The impact of LEGO Serious Play on business, and the expansion of this into healthcare practice are already well documented. The extent of the challenges that paramedics face in their everyday work necessitates a capacity to make meaning from experience; consolidate and challenge assumptions from clinical practice; and consider the potential for extension of these skills via social constructionist methodologies in undergraduate education and training and CPD (Burke et al, 2016).
The process also advocates the use of topical and sometimes very emotive challenges for focus in the LEGO Serious Play sessions. These potentially afford undergraduate and diplomate paramedic students, and the paramedic workforce who undertake annual CPD, the opportunity to consider how developing resilience is now an integral part of undergraduate education and ongoing developmental learning pathways.
The technique can also afford a collective shared experience and meaning-making in critical incidents that could potentially contribute to the development of PTSD. Narrative storytelling is a significant part of the process, enabling assumptions to be challenged and transformative learning opportunities in the affective domain.
A major consideration in the methodological approach is how personal resilience undoubtedly underpins the professional resilience mechanisms that can be actively taught and developed. What is experienced by paramedics will ultimately determine how resilient an individual paramedic is. However, positing whether resilience is a constant characteristic or in a dynamic state of flux is debatable in relation to the expectations, norms and cultures of the profession.
Where the technique is invaluable is in instances of complex ambiguity or abstraction in the context of perceived reality and experiential learning. Symbolism with the building blocks ensures a means of adding a dialogic mechanism of storytelling that reflects a perceived reality.
While the medium of LEGO Serious Play is pragmatic and straightforward in terms of the availability and reusability of the bricks, other media can be used. Typical examples are working with clay, sketching, and crafting with wooden models. The physical media for construction is largely irrelevant as long as it has the possibility of making the abstract concrete and visible. It is here that the building blocks can be particularly advantageous as they afford the opportunity of visually representing perceptions and disconnections and can readily be modified and changed to reflect specific circumstances. This dynamic feature gives what can be arguably regarded as an advantage in contrast to other media which remain static once they physically harden, such as in the case of clay.
Since engagement, immersion and flow are pivotal, LEGO Serious Play is ideal. The physical process of building allows participants to gain awareness of their own epistemic cognitions and individual assumptions, as well as develop and discuss ideas within a situationally-relevant setting (Bjørndahl et al, 2014). To a certain extent, the oxymoron of ‘serious play’ needs no further explanation in the context of building personal and collective resilience for paramedics as a profession. Whether as part of core undergraduate academic curricula or as a constituent part of CPD for the profession, the objective consideration of the narrative discourses generated ensure that the association of play with something purely subjective is nullified, and its seriousness is represented in the storytelling that ensues.
In relation to the challenging and situationally responsive climate in which paramedics work, LEGO Serious Play provides a clear opportunity to embed psychological resilience-building into the traditional affective domain learning of paramedic curricula.