The Role of Debriefing and Guided Reflection in Simulation

The Role of Debriefing and Guided Reflection in Simulation

Sharon Decker, RN, Ph.D., ACNS-BS, CCRN, ANEFSharon Decker, RN, Ph.D., ACNS-BS, CCRN, ANEF

ObjectivesObjectives

• Compare the strategies and models of debriefing and guided reflection.

• Explore the integration of debriefing and guided reflection during simulation.

Introduction: Changes in SocietyIntroduction: Changes in Society

• Experiencing more chronic co-morbidities

• Under 10 of age experiencing co-morbidities

• Living longer with increased chronic health needs

• Expect more input in health care decisions

• A broader view of medicine and health

How have these changes impacted-

how we deliver education?

competencies required for our discipline?

Health Educators’: Challenge #1Health Educators’: Challenge #1

IntroductionIntroduction

Challenges for the Health Educator

“requires complex, sophisticated judgments and psychomotor skills…” (p.128)

IOM, Crossing the Quality Chasm (2001)

Federal CommittionsFederal Committions

Institute of Medicine (2004)

• recommended teaching environments

– Require demonstration of competencies in patient-care delivery, evidence-based practice, quality improvement, and informatics

New nursing graduates have difficulty transferring knowledge and skills to the practice setting

Clarke & Aiken, 2003

Del Bueno, 2005

Health Educators’: Challenge #2Health Educators’: Challenge #2

And …

“New graduates….not prepared for the new quality improvement environment will require additional costly orientation and training.”

Finkelman, A & Kenner, C., 2007

Have we changed the methods used in teaching and assessing clinical competence to meet the changing environment?

Support for simulation by regulation agencies:

Support for simulation by regulation agencies:

For example:

National Council of State Boards of Nursing(2005)

Prelicensure nursing educational programs might include innovative teaching strategies (simulation) that complement

clinical experiences

Support for simulationSupport for simulation

Nursing faculty to “be open to a variety of clinical teaching models” including

virtual reality and

simulated clinical experience

AACN, 2003, p.13

Support for simulation Support for simulation

“New information and technologies

may require new skills. And new

technologies, such as simulation, may

enhance skills…” (p. 129)IOM, Crossing the Quality Chasm (2001)

National Council of State Boards of NursingNational Council of State Boards of Nursing

Simulation defined:

An educational process where learning experiences are simulated to imitate the working environment and require the learner to demonstrate the procedural techniques, decision-making, and critical thinking needed to provide safe and competency patient care.

Regulation agencies: Regulation agencies:

For example:

United States Medical Licensure Examination

Assesses clinical skills through simulated patient

interactions (Standardized patients)

Objective Structured Clinical Examinations (OSCE’s) allows measurement of skills in communication, professionalism, and physical assessment

Regulation agencies: Regulation agencies:

National Board for Respiratory Care

Includes a Clinical Simulation Examination which consists of 10 separate patient management problems

The National Registry of Emergency Medical Technicians

Investigating the use of high-fidelity simulation to assess psychomotor and decision making skills

Simulation as an Educational StrategySimulation as an Educational Strategy

Unique teaching tool that requires the educator to

● develop competencies with a new set of skills

● and be a risk taker.

Could simulation be one mechanism for

safe practice based learning?

Professional Charge for the FutureProfessional Charge for the Future

Therefore, if we must reinvent clinical teaching in practice based learning environments

Promoting Reflective ThinkingPromoting Reflective Thinking

Simulation =

Patient Care Experience

+

Debriefing and/or Guided Reflection

Experience alone does not guarantee learning Need the integration of reflection

(Boud, Keogh, & Walker, 1985)

Adult Learning PrinciplesAdult Learning Principles

Diverse Learning Styles

Visual (realism, fidelity of the environment)

Auditory (verbal responses)

Tactile (hear and lung sounds)

Kinesthetic (handling equipment)

Adult Learning PrinciplesAdult Learning Principles

Constructivism

Learning = process of constructing meaning

Educator functions as a collaborative facilitator

Includes experiential learning

Active engagement

Reflective thought

Reflection: DefinedReflection: Defined

The process that allows practitioners to uncover and expose thoughts, feelings and behaviors

A form of self-assessment/analysis that forces practitioners to face incongruity and uncomfortable facts

Philosophic FrameworkPhilosophic Framework

Dewey (1910, 1916)• Learning is dependent upon integration of experience with

reflection and of theory with practice

SchÖn (1987)• Learning promoted through the use of a “reflective practicum” –

learning environment realistic in which faculty act as coach

Philosophic FrameworkPhilosophic Framework

Kolb (1984)• Learning enhanced through a synergistic transaction between

learner and the environment

Bandura (1977)• Learning enhanced – self-confidence promoted with active learning

ReflectionReflection

SchÖn

Reflection-on-action– After the event

– Think back – gain understanding

Reflection-in-action– During

– Prompted by unexpected event

Knowing-in-action (Thoughtful Thinking)– Unconscious, initiative knowing

Stages of Reflective ThinkingStages of Reflective Thinking

Non reflectors Don’t identify relationships

Reflectors Identified relationships between new and past knowledge

Critical reflectors Identified relationships and demonstrated self-analysis

Mezirow, J. (1981)

Wong, Kember, Chung, & Yan (1995)

Reflective ThinkingReflective Thinking

Enhances learning from experience

Helps expand clinical knowledge

Promotes reflective practice

Improves clinical judgmentGlaze, J. E. (2001)

Paget, T. (2001)

Murphy, J. I. (2004)

Reflective ThinkingReflective Thinking

Patient care varies with the nurse’s reflective abilities

minimal reflective abilities = illness oriented patient care;

reflective skills = care based on the individualized needs of the client.

Conway (1998)

But, learning from reflection is not automaticBut, learning from reflection is not automatic

demands active involvement in a clinical experience (Teekman, 2000) and

guidance throughout the reflective process (Johns, 1996; Tanner, 1999).

Barriers & Outcomesof Reflective ThinkingBarriers & Outcomesof Reflective Thinking

Barriers

Previous learning Fixations Socialization (as a nurse) Organizational culture

Outcomes

Heightened self-confidence Empathy Understanding Better patient care

Environment and Tools Environment and Tools

Environment Safe – non-threatening, trustful Circle Confidential Time equal to or longer then the scenario

Setting the Ground RulesSetting the Ground Rules

Confidential

Review objectives and expectations

Professional courtesy No interruptions Respect

Supportive not judgmental Don’t talk about anyone not present Positive before negative

Listen

Audio-Visual IntegrationAudio-Visual Integration

• Be proficient with the equipment

• Do not show a segment unless it is to be discussed

• Show only 3 to 4 critical segments

• Index critical segments Introduce each segment

• “This segment occurred … discuss what you were thinking as you…”

Show the segment Pause – all the learner to self-critique

DiscussionDiscussion

Do you include audio-visual segment during each simulation?

When would they be appropriate?

Thing to think about:

Confidentiality forms

Archiving of materials

Faculty Role and ResponsibilitiesFaculty Role and Responsibilities

Dual role – facilitator and instructor

Facilitator

guide learner

Instructor

enhance understanding of “deficiencies”

Self-discovery

Faculty Role and ResponsibilitiesFaculty Role and Responsibilities

Set expectations (outline the process)

Guide the session

Facilitate according to level of engagement

Include “quiet” learners

Integrate instructional points

Reinforce

Faculty Role and ResponsibilitiesFaculty Role and Responsibilities

Give your analysis last

Keep the discussion “learner centered”

Be an active listener

Use silence and pauses

Use questioning – if appropriate to

encourage discussions

identify issues

explore other options

“Was there anything that occurred during the situation that made you uncomfortable?”

“What could you have done…?”

What is the difference between

Debriefing and Guided Reflection?

Break

DebriefingDebriefing

DebriefingDebriefing

A process in which after an experience the learner is lead through a purposeful discussion related to the experience

Lederman, 1992; Fanning & Gaba, 2007

Debriefing: PurposeDebriefing: Purpose

Correct errors

Identify different ways of handling event next time

Encourage self-assessment

Promote reflective thinking

Debriefing - WhenDebriefing - When

During – (Frozen) Emphasize teaching Defuse a deteriorating situation Redirect Limit embarrassment

After

Facilitation Techniques with DebriefingFacilitation Techniques with Debriefing

High-Level Facilitation –

guidance

Intermediate-Level Facilitation –

elicit continued or deeper discussion and analysis

Low-Level Facilitation –

refrain from interrupting and review objective

Debriefing ModelsDebriefing Models

Questioning

What did you experience?

How did you perform overall?

What have you learned?

How would you change your performance?

How can you apply learning to the future?

Debriefing ModelsDebriefing Models

Plus - Delta

Plus + Delta –

Behaviors to improve onInclude both what and how

Examples of good behaviors

Debriefing ModelsDebriefing Models

Advocacy – Inquiry “I noticed ….”

“I’m concerned…”

“I was wondering…”

DebriefingDebriefing

Summary

Correct any errors

Video for discussion

Guided ReflectionGuided Reflection

Guided ReflectionGuided Reflection

The process that allows practitioners to uncover and expose thoughts, feelings and behaviors

An active process of self-monitoring initiated by a state of doubt or puzzlement occurring during or after an experience

Guided Reflection: PurposeGuided Reflection: Purpose

Promotes insightfulness

Leads to discovery of new knowledge

New knowledge – to be applied in future situations

Guided Reflection: WhenGuided Reflection: When

Immediately after the experience

Guided Reflection: faculty (facilitator’s) role Guided Reflection: faculty (facilitator’s) role

Facilitator

Learners who make their own discoveries – even if disappointing are more likely to acknowledge and own these discoveries then if these insights are pointed out to them.

– Dewey, 1938

Guided Reflection: ModelsGuided Reflection: Models

DescriptionWhat happened?

Conclusionwhat else could you

have done?

Action PlanIf it arose

would you do?

FeelingsWhat were your

thinking & feeling?

EvaluationWhat was good &

bad about the experience?

AnalysisWhat sense can

you make ofthe situation?

Gibbs (1988)Reflective Cycle

Experience

WHAT?Describe the event

SO WHAT?Analysis the event

Discover what learning emerges from the

reflection

New learning

NOW WHAT?Proposed action

Purposeful reflection

Driscoll, 2000The WHAT Model Of Reflection

Johns, 1995, 1996(Based on Carper’s Ways of Knowing)Johns, 1995, 1996(Based on Carper’s Ways of Knowing)

Aesthetics “learning and knowing self” grasping, interpreting, envisioning and responding”

Describe what influenced your actions during the scenario.

Personal “understanding personal dynamics and the ability to cope with the situation”

Discuss your satisfaction with your

actions during this scenario.

Johns, Johns,

Ethics “knowing what is right and wrong and being committed to take action on this basis”

Describe how your personal values and beliefs influenced your actions during this experience.

Empirics “identifying and acknowledging lack of knowledge”

Describe the knowledge and skills you have that influenced your decision making during this experience.

Johns, Johns,

Reflexivity “resolve the contradictions between what the practitioner’s aim to achieve and actual practice, with the intent to achieve more desirable and effective practice”

Describe situations you have experienced as a student nurse that influenced your decision making during this experience.

Describe how this experience could have been handled differently.

Decker’s (Based on Johns Work) Decker’s (Based on Johns Work)

1. Talk to me about the problem your patient was having

2. What was your main goal during this simulation?

3. Tell me what influenced your actions during the scenario.

4. Talk to me about how this experience made you feel and how satisfied you are with the actions you initiated?

5. Talk to me about how your personal values and beliefs influenced your actions during this experience.

6. Talk to me about the knowledge and skills you have that helped you provide patient care during this simulated experience.

7. Talk to me about experiences you have had that influenced what you did during this scenario.

8. What would you do different if we went back into the patient’s room and repeated the scenario right now?

Factors Identified by Student Groups as Affecting Critical and Reflective Thinking During a Simulated Learning Experience

Factors Identified Percent of Groups a

Personal Response to Stress 50%

Perceived Self-Confidence 25%

Skills Competence 25%

Urgency of Task 17.8%

Experiential Knowledge 17.8%

Theoretical Knowledge 14.3%

Potential Legal Implications 10.7%a (N=28)

Decker, 2007

Additional Factors IdentifiedAdditional Factors Identified

• having tunnel vision (fixations) or focusing inappropriately on past experience,

• being resistant to change or having a defensive attitude,

• having poor communication skills,

• the inability to access appropriate resources both technical and human, and

• the learner’s cultural background.Decker, 2007

DiscussionDiscussion

As faculty how can we resolve these barriers?

Summary: ReflectionSummary: Reflection

Can be learned

Sufficient Time

Worthy experience Active experiential learning Clinically relevant

Learn by:• building knowledge on existing knowledge

• discovering what they know & what they do not know

Insight

Reflective ThinkingReflective Thinking

Learning from reflection is not

automatic –

It demands active involvement in clinical

experience and guidance

ReferencesReferences

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