Interprofessional Understanding of Ethical Dilemmas: Learning Experiences Of Simulation Learning in Social Welfare and Health Care Education

Archives > Volume 18 (2021) > Issue 2 > Item 06

DOI: 10.55521/10-018-206

Kaarina Mönkkönen, Dos., PhD.
University of Eastern Finland

Marja Silén-Lipponen, PhD.
Savonia University of Applied Sciences

Taru Kekoni, PhD.
University of Eastern Finland

Terhi Saaranen, Professor, PhD.
University of Eastern Finland

Journal of Social Work Values and Ethics • Volume 18(2), Copyright 2021 by IFSW

This text may be freely shared among individuals, but it may not be republished in any medium without express written consent from the authors and advance notification of IFSW.


This study examines the opportunities brought by simulation learning in acquiring interprofessional skills and developing ethical thinking. A large-scale simulation refers to a simulation utilizing drama carried out with the help of actors and professionals from various industries. The simulation was constructed around an emergency situation related to sudden infant death syndrome. The scenario involved a paramedic unit, police officers and an on-duty social worker. The study explored the ethical dilemmas emerging during the simulation training and a related simulation debriefing, and the opportunities simulation pedagogy provides for dealing with and learning about ethical conflicts.

The research data included a video-recorded simulation scenario and learning diaries by students based on a large-scale simulation, which were analyzed using narrative methods. The analysis was used as the basis for forming two main narratives representing key dilemmas. These included a person-oriented vs. action-oriented approach, and personal sense of justice vs. correctness. The shared ethical reflection resulted in the students understanding the moral justifications of professionals, such as police officers, physicians and paramedics, despite initially perceiving their activities critically. A key learning outcome was the broadening of the participants’ attitudes towards other professionals. They also raised their awareness of the significance of interprofessional collaboration and joint reflection in developing their own ethical thinking.

Keywords: Ethical dilemma, ethical decision-making, simulation learning, interprofessional cooperation, narrative analysis.


Interprofessional teamwork is particularly important in acute crisis situations. For example, such a situation can involve a paramedic, police officer and social worker arriving at a scene of an accident at the same time. Professionals must be able to work effectively together while also respecting patients or clients dealing with a human crisis. While the professionals may never have previously worked together, they all have implicit knowledge of the roles the other professionals play in the situation. In a crisis requiring interprofessional work, problems must be quickly solved, and there is no time for joint consideration on the solutions made by various professionals. However, the professionals may be left wondering about the solutions they or the other professionals have made, particularly regarding their ethical aspects (Frost et al., 2005; Lin et al., 2013).

In a crisis situation involving multiple professions, ethical reflection is not merely manifested as a clear decision by an individual professional; instead, tensions may arise in the collaboration between different operating approaches. Nevertheless, in their practical work, professionals encounter unpredictable situations which may complicate the implementation of these principles. Sarah Banks (2012), who has explored the ethical perspectives of social work, makes a distinction between conflicts and dilemmas. Conflicts occur more frequently and include some sort of discord between the person’s values and what is required by his or her job. By contrast, a dilemma involves two alternatives which are both correct in principle and of which neither is more morally right than the other (Banks, 2012; Banks & Williams, 2005).

Today’s vocational training and education includes practice of interpersonal situations between various professionals in contexts such as simulations of encountering clients. In simulation learning, students from different fields of education collaborate in solving clients’ issues and engage in joint reflection on why each participant acts in a certain way and what would be the right course of action. Collaborative learning and simulation of interpersonal situations have been considered to play a significant role in the development of the students’ interpersonal skills (Shrader et al. 2013; Nimmagadda & Murphy, 2014; Koponen & Julkunen, 2015; Saaranen et al 2020).

The present article examines a large-scale simulation organized for learning purposes in university education in the field of social welfare and health care. We use a narrative research approach for analyzing the ethical dilemmas in an interprofessional crisis situation, which emerged in a simulation of a crisis involving a sudden infant death syndrome. The simulation involved an interprofessional team consisting of a social worker, paramedics, a physician, and police officers. The theme of the simulation, the death of a child, was sensitive for both the professionals involved in performing in the drama as well as the students participating in the learning event.

The research question of this article was as follows: what kinds of ethical dilemmas emerged during the simulation and related simulation debriefing and how does simulation pedagogy provide an opportunity for dealing with and learning from ethical conflicts? In this study, we also highlight the significance of interprofessional learning in the form of activities promoting ethical argumentation among professionals.

Study issue: interprofessional simulation learning in developing ethical thinking

Ethical dilemmas in an acute crisis situation

While the issues of professional ethics have been explored in various fields (e.g., Mendes et al., 2015; Shapira-Lishchinsky, 2011), the amount of research focused on ethical dilemmas arising in the interprofessional context is rather small. In an interprofessional team, the activities by the representatives of another professional group may be subject to criticism if the premises of the work are highly different and some aspect of the work is in conflict with the members’ ethical principles (Blakey, 2014). Ethical decision-making may include contradictory principles, such as the client’s need, the technical-bureaucratic conditions of the service, requirements concerning financial efficiency, a wish to advocate for the client, or an aim of taking care of one’s job in the correct way from a professional perspective (Banks, 2012; Beckett, Maynard & Jordan, 2017). Ethical argumentation involves a professional selecting one agent (such as the client, organization, one’s professional group, society) whose voice the professional uses to talk about or compare various perspectives (Frost et al., 2005).  Ethical dilemmas, then, emerge in different conflict situations that force professionals to make a choice between two or more operating approaches, selecting the alternative the person believes will cause least harm or greatest benefit.         

While every professional group emphasizes its own ethical aspects, different groups also have joint principles, including clients’ privacy, compassion, individuality, and showing respect when encountering clients. However, the concepts used for describing these vary. For instance, the ethical principles of social work strongly emphasize client advocacy, paying attention to the overall situation, and social justice (IFSW, 2018). By contrast, the ethical principles of the police highlight reliability and honesty and basing all activities on correct information. The authority of the police force must respect human dignity in compliance with valid legislation. (College of Policing Limited, 2014.) Medicine, for its part, aims at minimizing the harm caused to patients, and treatment and care must comply with care guidelines (The National Advisory Board on Social Welfare and Health Care Ethics, 2018; The Finnish Medical Association, 2020; Lin et al ., 2013). Professionals are also likely to experience different emotions when encountering a serious crisis situation with distressed and grieving people.  These situations also tend to require making quick decisions, and there is often no time to reflect on the situation with other professionals. In such cases, a personal sense of justice particularly guides the activities of each professional (Rawls, 1999; Dennis, 2008). While the concept of the sense of justice is difficult to determine in detail, it emerges in situations in which solving an issue solely based on the available rules does not feel right, in which case professional decision-making is also guided by intuition.

In previous research, ethical dilemmas have been categorized into dilemmas that leave professionals feeling uncertain about how to act in a given situation, and ones that require professionals to act in contradiction with general rules. Such situations often include some unexpected turn of events, which requires ethical consideration (Banks, 2012). In health care, complicated decision-making situations arise in contexts such as ending the active treatment of a terminal illness (Lin et al., 2013). Such situations affect professionals emotionally and are also always mirrored on the personal values to the professionals. There may also be variation in the interpretations related to confidentiality between different professionals (Blakey, 2014; Rogers, 2018).

Interprofessional simulation learning in developing ethical thinking

Simulation learning provides an important working approach for examining ethical questions, particularly in an interprofessional context. Professional collaboration plays a major role in minimizing medical errors and ensuring overall client and patient safety, for instance (Mehta et al., 2013). Research findings have confirmed that interprofessional education improves collaboration, and reduces prejudice, between professions (Schrader et al., 2013; Frost et al., 2005). Interprofessional education (IPE) aims at creating capabilities between professions for the purpose of providing clients with coordinated treatment or services. From a learning perspective, it is important that the participants in IPE jointly reflect on how each person acts in a certain way and which motives and goals the person attributes to his or her actions (Lin et al., 2013).

A simulation provides a safe environment for practicing genuine, even critical, situations, without endangering patients. Simulation learning occurs in a variety of contexts, including role play and virtual practices. In comprehensive scenario-based simulations students are provided with a realistic, dynamically progressing case that may include activities and decision-making occurring on various levels (Dieckmann et al., 2009.)

The simulation progresses from a briefing and a simulation scenario to a debriefing (Shinnick et al., 2011; Tervaskanto-Mäentausta, 2018). In a traditional simulation, learners are either active agents or observers and learn according to the goals set for the simulation. While the emotional experience of the simulation can be powerful for those with active roles, observers also learn by following and empathizing with the roles of those actively participating (Rode et al., 2006),

A large-scale simulation is a new method of simulation pedagogy that involves utilizing the traditional small group simulation learning with a large group of learners. The main difference compared to traditional scenario-based simulation is that the group participating is larger than the traditional simulations. (Rode et al., 2006). In Eastern Finland, large-scale simulations have been implemented since the autumn of 2017 in collaboration with the departments of pharmacy, dentistry, nursing science, medicine and social sciences at a university, universities of applied sciences, and a university hospital. 

In the studied large-scale simulation, professionals were asked to act similarly as they would if they encountered the situation in real life. While the facilitator’s task involved posing questions to obtain further information from the participants during the simulation debriefing, the aim was to otherwise provide a platform for the participants’ own experiences. (Dieckmann et al. 2009). As mentioned above, the simulation scenario of this study was related to a crisis situation, and started as follows:

Parents find their child lifeless in the morning and call the emergency center. Four paramedics arrive at the scene and start resuscitating the child. Once the resuscitation has been continued for long enough, an emergency care physician, contacted via a remote link, informs the paramedics that they must stop resuscitating as the efforts are unsuccessful. Two police officers and an on-duty social worker are called to the scene.

The scenario was watched by a large group of students in medicine, nursing science, pharmacy, social work and psychology, and professionals in social welfare and health care (n=427). The roles of the drama were played by professional actors (as the child’s parents) and professionals from various fields (paramedics, police officers, a social worker, and an emergency care physician). The simulation followed a joint debriefing which involved the performers reflecting on the significance of the choices they had made and emotions they had felt during the simulation (Dickemann et al., 2009; Dufrene & Yang, 2014; Aura et al., 2016). Subsequently, everyone else involved in the learning event participated in the discussion.

Methods: Narrative analysis in examining ethical dilemmas

The aim of the simulation examined in the present article was to promote interprofessional learning in general. However, ethical questions often arose during the simulation reflection included in the learning session.

This study did not involve consciously highlighting ethical issues during the simulation debriefing, and no separate questions on the topic were included in the instructions provided on the students’ learning assignments. Ethical dilemmas surfaced as a significant finding in the reflection by the professionals during the simulation debriefing and in the students’ learning diaries. This resulted in a need for further examination of the topic.

This is a qualitative, narrative study utilizing multimodal video data of the large-scale simulation and learning assignments the students completed based on the simulation. The methodological background orientation of this study is focused on the main premises of social constructionism on producing a shared social reality through language by affording things social meanings (Gergen, 2009; Flick, 2015).  The data were analyzed using the narrative analysis method, which involved examining the data as a whole, looking for essential comprehensive meanings related to ethical dilemmas (Polkinghorne 1988; Hänninen 2004). The Atlas.ti software was used as support for the analysis. The material was read several times over to identify themes contained by the narratives. Participating in a simulation, transcribing videos and reading learning diaries provided the researchers with an opportunity for in-depth knowledge of the data.

The data consist of video material of the simulation debriefing related to the large-scale simulation (1.5 hours) and 45 learning diaries, which were on average five pages in length. The learning diaries were assignments written by social welfare and social psychology students. The instructions included reflecting on large-scale simulations from the viewpoint of personal learning. The learning diaries involved a relatively high amount of ethical consideration, and these sections of the learning diaries served as the data for this study. Content that stirred ethical consideration was selected from the simulation debriefing video (in total around 20 min.) which was then edited and transcribed for closer analysis. The video material of the actual scenario served as support material in interpreting the narratives, as the atmosphere and emotions stirred by the discussion could be identified from these. The interactions between different agents was not the topic of study; instead, the focus was rather on the topics addressed by the participants in relation to the context of the discussion.

Excerpts concerning ethical dilemmas were selected from the total data which we will hereinafter refer to as sub-narratives. Two main thematic wholes could be formed based on the sub-narratives (N111, 22 pages), which we will refer to as core narratives. Each core narrative was paired with an opposing perspective in the context of the debriefing. As these opposing views fulfilled the characteristics of a dilemma, they were reconstructed into a major narrative, i.e., a situation-specific dilemma. The narratives interpreted as ethical dilemmas clearly concerned tension between two different alternatives for action, both correct in principle, and which participants observing the simulation highlighted both in their reflection.

The below figure (Figure 1), as an example, presents the conceptualization of the ethical dilemmas at the analysis stage of this study. Narratives describing the expansion of the narrator’s perspective based on the learning experience or involving clear assessment of various perspectives illustrated interprofessional learning.  The code following each sub-narrative indicates which core narrative each sub-narrative concern (A/B), and whether the informant is a professional (P) or a student (S). Three dots (…) have been used to indicate short pauses in speech. Information is also given in writing on whether the narrator is a student or a professional. For the latter, we have also reported which professional group the person represents.

Figure 1: Conceptualization of the ethical dilemmas at the analysis stage of this study

Research findings

Person-oriented vs. action-oriented approach

The research findings were structured into two ethical dilemmas, which formed essential thematic entities in the simulation debriefings and learning diaries. The third sub-section also includes separate examination of the perspectives presented by the students in relation with interprofessional learning even though these are also partly presented in the examination of ethical dilemmas.

In the context of interprofessional work, dilemmas must be considered to not only concern the right or wrong operating approaches, but also if the operations of each professional are correct from some perspective. The topics particularly stirring discussion were related to the situations portrayed in the simulation scenario that involved a) asking the parents to move to the kitchen during the resuscitation, b) stopping resuscitating the child, and c) the paramedic handing the deceased child over to the parents so they can say goodbye to their child, and d) the arrival of the police to the scene to investigate the matter.

These situations prepared the participants to discuss what sort of tension there is between efficiency and encountering clients in a crisis, what is allowed in practicing a profession, and which lines may be crossed. The discussion was divided into three perspectives. The first theme involved encountering a client in a crisis, including aspects such as an ability to interpret situations, encounter clients sensitively, and the significance of communications respectful to the clients. Second, the narratives also involved consideration of the professionals’ different orientation to the situation.  The straightforward and action-oriented approach of the police officers made them stand out from the others. Third, the participants reflected on the role of emotions as part of the profession in the context of retaining professional functional capacity.

Encountering the death of a child is always emotionally difficult, also for professionals, which can also pose a challenge to professionalism. The professionals described experiencing moments when time seems to stop during the crisis scenario. This could result in the professionals acting differently than in other situations. One of the paramedics reflected on the issue as follows:

It was impossible to start and pack up your things in that moment … or do anything or say anything … I felt that I just had to be there, in that moment.

The significance of nonverbal communications during a crisis was often emphasized by the students. They pointed out that clients are likely to remember the small gestures and the words spoken during a sensitive situation for a long time.

The paramedics and social worker did particularly well in using non-verbal communications to express how sorry they were for the clients’ loss. Touching the client is a powerful means of expressing empathy and understanding for the client’s situation.

From a perspective of interprofessional learning, considering the issue of nonverbal communications based on the different roles of the professionals is important. In this context, tension emerged in connection with the empathy related to the situation and the actions required by problem-solving. The debriefing also helped the participants see the activities of the police officers in a new light.

While the viewers were at times confused by the behavior of the police officers, this job requires the professionals to act rationally, do what the situation requires and ensure that their responsibility is not threatened by anything.

As the students’ narratives and comments referred to the behavior of the police officers as “strict,” the debriefing required the police officers to explain the nature of their basic assignment in a criminal investigation to the audience, therefore justifying their choices during the scenario. The debriefing helped the audience to also see a more compassionate dimension in the work of the police officers, as the event included an officer reflecting on personal experiences of the death of a child witnessed at work.  The following excerpt illustrates both the role required by the profession and the individual’s personal emotions related to the death.

The work of a police officer is about forming a mental image. What information has been given, does it match the evidence…But then, as an individual, you think about how the parents must be feeling…think about your own children. My goodness, they have just lost a child. That really stops you in your tracks.

The issue of showing personal emotions made both professionals and students reflect on what emotions may be shown in the situation. This was particularly examined as a source of tension related to professionalism and showing emotions.

I’ve encountered a few situations that put tears in my eyes… But I still tried to maintain my role as a professional there, remembering that I am there to help… We’re all people, after all… I could imagine that if the parents see tears in the eyes of those who help them, it will not upset them.

A great deal of critical discussion emerged among the students and audience related to a situation involving one of the police officers asking the parents to move to the kitchen for the course of the investigation and put their deceased child back on the table. The audience members asked why the parents were not allowed to be in the same room during the resuscitation and investigation. The students reported having felt irritated because of the actions by the police and paramedics when watching the scenario, but later understanding that a crisis situation requires short and direct commands. This was also confirmed by the actor playing the father in the drama, who describes his experiences of the situation as follows:

You can only understand direct commands. Not someone patting your hand and gently asking you to do something. In a situation like that, you only do what you’re told. It may sound strange, but when someone has died, and your grief has poured out. It´s like you’re on autopilot. Direct commands, no alternative.

The leader of the paramedic team also emphasized the importance of safeguarding professional functional capacity to ensure that the paramedics resuscitating the child can take care of their duty undisturbed: Perspectives of encountering a crisis were also presented from the viewpoints of emotional and practical support.

The social worker took on a role as a person present in the situation, handing tissues to the parents and making it okay for them to cry in peace, while also showing compassion with touch. She described the nature of on-duty social work, confirming that parents must not be left alone in this situation. The social worker also highlighted the sensitivity of the issues, as the role involves retaining the ability to ask concrete questions regarding support for everyday life.

You have to be able to read the situation quite a lot, even though I started by asking a lot of questions. You have to highlight the most important issues. Always include written instructions. From a perspective of consequences, it is important not to leave the scene before someone else arrives there… the family’s networks also tend to get activated at this point.

As a whole, this conversation was summarized as two dilemmatic core narratives: a person-oriented approach involving presence with the clients and retaining professional functional capacity. Both dimensions are essential components of applicable professional principles in a crisis situation. Both perspectives also exist in a relationship involving tension in many tasks in social welfare and health care.

Personal sense of justice versus correctness

The large-scale simulation stirred a lot of discussion on a sense of justice and correctness. The scene involving giving the dead child to the arms of the parents for the final time was particularly touching. This took place after the decision of stopping resuscitation had been made and the paramedics had ceased resuscitating the child. After this, they calmly set their emergency care equipment aside and had a moment of silence for the child. After this, one of the paramedics asked the parents if they would like to say goodbye to their child before the child is taken away. The child was handed over to the father, who held the child until the police arrived at the scene.

During the debriefing, a question emerged from the audience regarding whether the child should be handed to the parents and all paramedic equipment removed from the scene, or whether the child should be left on the table. This topic was also addressed in many learning diaries, stirring strong emotions and varying views. The paramedics teacher who led the discussion asked the police officer performing in the scene about the issue of handing over the child, whose answer was as follows:

For a police officer, this is a very bad decision. What if there’s a medical error there?… What if something has been done incorrectly? If that is the cause of death… Absolutely not.

The emergency care physician confirmed what the police officer said, putting emphasis on the mandatory nature of instructions. The physician highly emphasized this, also based on long experience in encountering similar situations. The message given to the audience was that following this procedure is vital for the purpose of determining the cause of death. The physician’s viewpoint was guided by a strong and uncompromising principle of correctness that excludes any other alternatives for action. Therefore, the physician did not perceive the issue as a dilemma, in contrast with some of the audience members.

You may not remove any equipment, if the patient has an intubation tube, an oral airway, a laryngeal mask… any cannulas must be left where they were, as this child will be taken to an autopsy in forensic medicine… And the child may not be removed from the table, as the police must get photos of the scene of the incident… It’s just the way it is.

After the physician had spoken, the facilitator of the discussion asked how the professionals involved in the simulation would act in a similar situation in the future. This question was particularly addressed to the paramedics. The answer given by the paramedics provided more in-depth information about the nature of ethical dilemmas. In this episode, paramedics spoke about the issue very quietly, at times interrupting what they were saying. This reflected the sensitivity of the topic to them. All the paramedics felt that they were forced to act in contradiction to the official guidelines in this situation. Paramedic 1:

But a child… I know… fully well you’re not supposed to move it. But if a crying parent asks to hold their child, I don’t know if I have what it takes to deny them… I honestly cannot say.

Paramedic 2: I could not act in any other way than by handing the child over to the parents if this was what the parents asked for.

Paramedic 3: I absolutely agree… I don’t think you could refuse to hand the child over to the parents… I don’t think anyone could refuse it.

The above discussion is clearly divided into two opposing views. According to the physician and police officer, no medical equipment may be removed due to reasons related to the investigation. By contrast, the paramedics indicate that while they are aware of this rule, they made the choice they did based on compassion felt towards the parents. In the learning diaries, this episode manifested as reflection from both an ethical perspective and from the viewpoint of the operating process. The students could particularly identify with the solution made by the paramedics, but also had no trouble understanding the viewpoint of the police and the physician.

Many different factors were presented on how activities perceived as compassionate may meddle with and harm the police investigation.

What we have here is a humane perspective against a clinical perspective. The paramedics commented that it’s hard to deny a parent a possibility to hold the child to say goodbye, even though as a rule, this should not be done. This is very understandable.

The students also considered that the shared debriefing provided them with information about the moral justifications related to the issue. The professionals performing in the drama could also see the situation in a new light, which fortified the significance of the debriefing and shared reflection among the professionals.

Increasing understanding of the activities by different professions

As noted above, the students initially perceived the straightforward operating approach of the police officers as inhumane, “harsh” or “cold” in the crisis situation. However, nearly all of the students also reflected on a change in their attitudes and raising their awareness of the operating logic of the professions in this context.

This event helped me understand even more deeply how every professional group has a different perspective on things, and therefore also varying interests. For example, from an empathetic perspective, the way the police officers act in this sort of a situation can be seen as very insensitive, but this is actually all down to their different role as professionals and their part in all of this.

The learning diaries revealed that the simulation had led to realizing important things about encountering a client in crisis. The students and participants understood that the professionals do not have clear operating instructions for the most highly demanding situations, as a result of which interpersonal interactions gain prominence in this context.  Despite the different professional backgrounds, encountering the individuals was perceived as an overarching factor, and each professional was perceived as a human agent, even in their professional roles. Many of the students reported that the simulation had “gone under their skin.” This made it vital to reflect on related emotions and attitudes.’

Underneath a professional exterior is a human being with emotions, who finds it easy to put him/herself in the place of the distraught client. I believe this is invaluable when you’re engaging in work that involves interpersonal relationships.

The following excerpts summarize the core idea of interprofessional learning regarding understanding the activities by different professional fields and an ability to see beyond personal professional role.

While interprofessional collaboration enables the members of a team to learn from one another, it requires a right kind of an attitude in the interprofessional team.  The members must be able to see beyond the limits of their professional competence and accept that someone representing a different profession may have better command of some areas.

According to the research data, the simulation provided an important opportunity for identifying dilemmas in professional ethics and understanding the justifications for the activities by each professional group. 

Discussion and conclusion

The dilemmas in professional ethics have been previously studied by exploring either the ethical language used by professionals or phenomena that professionals have identified as ethical dilemmas (Banks & Williams, 2005). In the present study, dilemmas emerged in the narratives produced by professionals and students without having to separately ask about the issue. We believe that it is also important to examine ethical phenomena through real-life situations that involve problem solving. Simulation pedagogy provided an important tool for this.

This study included reflection on ethical dilemmas based on a simulated interprofessional crisis situation and related learning. Figure 1 presents key research findings. Two main narratives emerged from the data: a person-oriented vs. action-oriented approach and a personal sense of justice vs. correctness (column 1). The core narratives and their moral justifications are presented in the second and third column. In this study, “moral justifications” refer to perceiving the activities by the professionals as right or correct based on some perspective. The narratives related to a person-oriented approach demonstrated human compassion during encounters and display of emotions by the professionals and emphasized the significance of non-verbal communications in the crisis encountered by clients. The narratives emphasizing an action orientation, categorized as the “opposite” of a person orientation, focused on objectivity, retaining professional functional capacity, and careful compliance with one’s professional task. In turn, the narratives representing a personal sense of justice put emphasis on following one’s personal sense of justice and the ability to e empathize with others. This was contrasted with narratives focusing on correctness manifested as investigating objective facts and careful compliance with instructions.

Figure 2: Ethical dilemma and moral justifications of core narrative

The simulation prepared the students for reflecting on issues significant to interprofessional learning, including understanding the professional roles of others, changing previous attitudes, ethical reflection, and the significance of interprofessional work The most essential learning outcome concerned a change in personal attitudes towards other professionals, which had also been set as one of the most important goals of the interprofessional simulation. Other key learning outcomes included understanding the ethical choices involved in other professional roles and the fact that all professionals work based on principles related to their activities.

Figure 3: Learning outcomes of interprofessional simulation learning

Narrative research perceives narratives as an opportunity for self-positioning, which means that speakers position themselves in relation with others while simultaneously constructing their identities through narration by giving moral meanings to issues (Harré & van Langenhove, 2003; Hirvonen, 2016). In an ethically demanding situation, professionals also reflect on their activities in relation to their professional identities. In our research data, this could be seen as moral negotiation related to the basic task of each profession, through which different professionals and students expanded their views of the ways other professionals operate, as a result revising and complementing their previous assumptions. At the same time, the participants advanced their know-how related to interprofessional crises, which manifested as an understanding of the integration of sensitive encountering and professional functional capacity.

In interprofessional collaboration, tension particularly arises from the different premises for the professional ethics of various occupations, even though these all share the principles of respecting human dignity and carefully managing one’s basic task. Ethical dilemmas can also emerge from different ways of understanding the effectiveness of work as well as the participants’ professional authority (Rogers, 2018).

While professional roles affect problem-solving situations, many aspects of encountering clients are the same for everyone involved, as was also apparent in the students’ learning diaries. The moral development of vocational students has been previously studied through biennial interviews of undergraduate social welfare and law enforcement students (Juujärvi, 2003). The moral reasoning of the students was particularly evaluated from the perspectives of caring and fairness. There were hardly any differences in the moral development of the social welfare and law enforcement students, despite the fact that the student police officers train as law and order enforcers while the social welfare students’ work involves care and support. The dimensions of moral decision-making, caring and fairness, develop side by side, and support each other in the students’ professional development. (Juujärvi, 2003). This may lead to a conclusion that the different interpretations of professionals are more closely connected to a specific situation and role than the moral functional capacity of the profession.

Interprofessional learning also develops individual professional identity and ethical thinking. It’s based on joint act in the best interests of the clients and challenges unjust or harmful rules (Juujärvi et al. 2020; Weinberg & Banks 2019). Members of a single profession may also experience interprofessional collaboration in various ways. Rydenfält et al. (2018) found that perceptions of the interprofessional teamwork varied among physicians. The physicians emphasized that collaboration in interprofessional team creates additional value to the work, and it demands determining clear roles and joint objectives for professional team and having a psychologically safe atmosphere in the group (Rydenfält et. al., 2018) research in social work and nursing science has also revealed similar perspectives (Bronstein 2003; Schaik, Plant & O’Brien, 2015; Wang & Petrini, 2017). Ethical argumentation requires a safe atmosphere, as this encourages the parties to present their views, including criticism, and openly express their emotions. This enables making the requirements set for each person’s role and basic task visible. (Frost et al., 2005.)

In the context of interprofessional collaboration, ethical assessment must not be examined based on a single interpretation, one that is either right or wrong, as this often results in ignoring the context of the situation and the effect of the professional’s duty on the solutions.  The development of ethical competence requires providing professionals with an opportunity for joint reflection to reveal all perspectives related to individual situations (Kulju, Stolt, Suhonen & Leino-Kilpi, 2016). It is also important to examine ethical dilemmas in an interprofessional context to enable professionals and students to recognize the importance of interprofessional collaboration and reflection for developing their personal ethical thinking. This is also the idea underlying the significance of interprofessional simulation learning.


Aura, S., Jordan, S., Saano, S., Tossavainen, K., & Turunen, H. (2016). Transfer of learning:

Radiographers’ perceptions of simulation based educational intervention. Radiography 22(3), 228–236.

Banks, S. (2012). Ethics and values in social work (1st ed.). Palgrave.

Banks, S., & Williams, R. (2005). Accounting for ethical difficulties in social welfare work: Issues, problems and dilemmas. British Journal of Social Work, 35(7), 1005–1022.

Beckett, C., Maynard, A., & Jordan, P. (2017). Values & ethics in social work. Sage.

Blakey, J. (2014). We’re all in this together: Moving toward an interdisciplinary model of practice between child protection and substance abuse treatment professionals. Journal of Public Child Welfare, 8(5), 491–513.

Bronstein, L. R. (2003). A model for interdisciplinary collaboration. Social Work, 48(3), 297–306.

College of Policing Limited. (2014). A code of practice for the principles and standards of professional behavior for the policing profession of England and Wales.

Dennis, L. K. (2008). Evolution of a sense of justice. Victims of Crime, 5(2), 229–245.

Dieckmann, P., Molin, F. S., Lippert, A., & Ostergaard D. (2009). The art and science of debriefing in simulation: ideal and practice. Medical Teacher, 31(7), 287–94.

Dufrene, C., & Young, A. (2014). Successful debriefing – Best methods to achieve positive learning outcomes: A literature review. Nurse Education Today, 34(3), 372–376.

Finnish National Board on Research Integrity. (2019). Responsible conduct of research and procedures for handling allegations of misconduct in Finland. Retrieved March 26, 2020, from

Flick, U. (2015). An introduction to qualitative research (4th ed.). Sage.

Frost, N., Robinson, M., & Anning, A. (2005). Social workers in multidisciplinary teams: Issues and dilemmas for professional practice. Child and Family Social Work, 10(3), 187–196.

Gergen, K. (2009). Relational being: Beyond self and community. Harvard University Press.

Harré, R., & van Langenhove, L. V. (2003). Positioning theory: Moral contexts of intentional action. Blackwell.

Hirvonen, P. (2016). Positioning theory and small-group interaction: Social and task positioning in the context of joint decision-making. Sage Open, 6(3), 1–15.

Hänninen, V. (2004). A model of narrative circulation. Narrative Inquiry, 14(1), 69–85.

IFSW – Ethics in Social Work, Statement of Principles. (2018). International Federation of Social Workers.

Juujärvi, S., Kallunki., & Luostari, H. (2020). Ethical decision-making of social welfare workers in the transition of services: The ethics of care and justice perspectives, Ethics and Social Welfare,14(1), 65-83.

Juujärvi, S. (2003). The ethic care of its development. A longitudinal study among practical nursing, bachelor’s degree social and law enforcement. Doctoral theses.Helsinki: University of Helsinki. 

Koponen, J., & Julkunen S. (2015). Theoretical principles of simulation-based sales communication training. Simulation & Gaming, 46(2), 137–147.

Kulju, K., Stolt, M., Suhonen, R., & Leino-Kilpi, H. (2016). Ethical competence: A concept analysis. Nursing Ethics, 23(4), 401–412.

Lin, Y. C., Chan, T. F., Lai, C. S., Chin, C. C., Chou, F. H., & Lin, H. J. (2013). The impact of an interprofessional problem-based learning curriculum of clinical ethics on medical and nursing students’ attitudes and ability of interprofessional collaboration: A pilot study. Kaohsiung Journal of Medical Science, 29(9), 505–511.

Mendes, S.A., Nascimento, I.M.G., & Abreu-Lima I. M.P.  (2015). Study of the ethical dilemmas experienced by school psychologists in Portugal. Ethics & Behavior, 26(5), 395–414.

Mehta, N., Boynton, C., Boss, L., Morris, H., & Tatla, T. (2013). Multidisciplinary difficult airway simulation training: Two-year evaluation and validation of a novel training approach at a district general hospital based in the UK. European Archives of Oto-Rhino-Laryngology, 270(1), 211–217.

Nimmagadda, J., & Murphy, J. (2014). Using simulations to enhance interprofessional competencies for social work and nursing students. Social Work Education, 33(4), 539–548.

Polkinghorne, D. E. (1988). Narrative knowing and the human sciences. State University of New York Press.

Rawls, J. (1999). A theory of justice. Harvard University Press.

Rode, J., Callihan, M., & Barnes, B. (2006).  Assessing the value of large-group simulation in the classroom. Clinical Simulation in Nursing, 12(7), 251–259.

Rogers, M. (2018). Ethical dilemmas facing clinical supervisors in integrated health care settings. Journal of Social Work Values and Ethics, 2(15), 23–36.

Rydenfält, C., Borell, J., & Erlingsdottir, G. (2018). What do doctors mean when they talk about teamwork? Possible implications for interprofessional care. Journal of Interprofessional Care, 33(6), 714–723.

Saaranen, T., Silen-Lipponen M., Palkolahti M., Mönkkönen, K., Tiihonen, M., Sormunen, M. 2020. Interprofessional learning in social and health care –Learning experiences from large‐group simulation in Finland. Nursing Open, Retrieved August 26, 2020

Shapira-Lishchinsky, O. (2011). Teachers’ critical incidents: Ethical dilemmas in teaching practice. Teaching and Teacher Education, 278(3), 648–656.

Schaik, S., Plant, J., & O’Brien, B. (2015). Challenges of interprofessional team training: A qualitative analysis of residents’ perceptions. Education for Health, 28(1), 52–57.

Shrader, S., Kern, D., Zoller, J., & Blue, A. (2013). Interprofessional teamwork skills as predictors of clinical outcomes in a simulated healthcare setting. Journal of Allied Health, 42(1), 1–6.

Shinnick, M., Woo. M., Horwich, T., & Steadman, R. (2011). Debriefing: The most important component in simulation? Clinical Simulation in Nursing, 7(3), 105–111.

The National Advisory Board on Social Welfare and Health Care Ethics. (2018). Retrieved March 26, 2020, from

The Finnish Medical Association.  Retrieved March 26, 2020, from

Tervaskanto-Mäentausta, T. (2018). Interprofessional education during undergraduate medical and health care studies. Doctoral thesis. Oulu: University of Oulu.

Wang, J., & Petrini, M. (2017). Chinese health students’ perceptions of simulation-based interprofessional learning. Clinical Simulation in Nursing, 13(4), 168–175.

Weinberg, M. & Banks, S. (2019). Practicing ethically in unethical times: Everyday resistance in social work. Ethics and Social Welfare,13(4), 361–376.