The Role of Debriefing and Guided Reflection in Simulation

1. The Role of Debriefing and Guided Reflection in Simulation Sharon Decker, RN, Ph.D., ACNS-BS, CCRN, ANEF

2. Objectives • Compare the strategies and models of debriefing and guided reflection. • Explore the integration of debriefing and guided reflection during simulation.

3. Introduction: 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

4. Health Educators’: Challenge #1 • How have these changes impacted- • how we deliver education? • competencies required for our discipline?

5. Introduction • Challenges for the Health Educator “requires complex, sophisticated judgments and psychomotor skills…” (p.128) • IOM, Crossing the Quality Chasm (2001)

6. Federal Committions • Institute of Medicine (2004) • recommended teaching environments • Require demonstration of competencies in patient-care delivery, evidence-based practice, quality improvement, and informatics

7. Health Educators’: Challenge #2 • New nursing graduates have difficulty transferring knowledge and skills to the practice setting • Clarke & Aiken, 2003 • Del Bueno, 2005

8. And … • “New graduates….not prepared for the new quality improvement environment will require additional costly orientation and training.” • Finkelman, A & Kenner, C., 2007

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

10. 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

11. Support 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

12. 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)

13. National 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.

14. 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

15. 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

16. Simulation 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.

17. Professional Charge for the Future • Therefore, if we must reinvent clinical teaching in practice based learning environments Could simulation be one mechanism for safe practice based learning?

18. Promoting 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)

19. Adult Learning Principles • Diverse Learning Styles • Visual (realism, fidelity of the environment) • Auditory (verbal responses) • Tactile (hear and lung sounds) • Kinesthetic (handling equipment)

20. Adult Learning Principles • Constructivism • Learning = process of constructing meaning • Educator functions as a collaborative facilitator • Includes experiential learning • Active engagement • Reflective thought

21. Reflection: 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

22. Philosophic 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

23. Philosophic Framework Kolb (1984) Learning enhanced through a synergistic transaction between learner and the environment Bandura (1977) Learning enhanced – self-confidence promoted with active learning

24. Reflection • 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

25. Stages 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)

26. Reflective Thinking • Enhances learning from experience • Helps expand clinical knowledge • Promotes reflective practice • Improves clinical judgment • Glaze, J. E. (2001) Paget, T. (2001) Murphy, J. I. (2004)

27. Reflective 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)

28. But, 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).

29. Barriers & Outcomesof Reflective Thinking Barriers Previous learning Fixations Socialization (as a nurse) Organizational culture Outcomes Heightened self-confidence Empathy Understanding Better patient care

30. Environment and Tools • Environment • Safe – non-threatening, trustful • Circle • Confidential • Time equal to or longer then the scenario

31. Setting 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

32. Audio-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

33. Discussion • Do you include audio-visual segment during each simulation? • When would they be appropriate? • Thing to think about: • Confidentiality forms • Archiving of materials

34. Faculty Role and Responsibilities • Dual role – facilitator and instructor • Facilitator • guide learner • Instructor • enhance understanding of “deficiencies” Self-discovery

35. Faculty Role and Responsibilities • Set expectations (outline the process) • Guide the session • Facilitate according to level of engagement • Include “quiet” learners • Integrate instructional points • Reinforce

36. Faculty 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…?”

37. Break What is the difference between Debriefing and Guided Reflection?

38. Debriefing

39. Debriefing • A process in which after an experience the learner is lead through a purposeful discussion related to the experience • Lederman, 1992; Fanning & Gaba, 2007

40. Debriefing: Purpose • Correct errors • Identify different ways of handling event next time • Encourage self-assessment • Promote reflective thinking

41. Debriefing - When • During – (Frozen) • Emphasize teaching • Defuse a deteriorating situation • Redirect • Limit embarrassment • After

42. Facilitation 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

43. Debriefing 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?

44. Debriefing Models • Plus - Delta Delta – Plus + Examples of good behaviors Behaviors to improve on Include both what and how

45. Debriefing Models • Advocacy – Inquiry • “I noticed ….” • “I’m concerned…” • “I was wondering…”

46. Debriefing • Summary • Correct any errors Video for discussion

47. Guided Reflection

48. Guided 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

49. Guided Reflection: Purpose • Promotes insightfulness • Leads to discovery of new knowledge • New knowledge – to be applied in future situations

50. Guided Reflection: When • Immediately after the experience