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

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• 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
  (OSCEs) 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
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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?
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Promoting Reflective Thinking
Experience alone does not guarantee learning
Need the integration of reflection (Boud,
Keogh, Walker, 1985)

• Simulation
• Patient Care Experience
• Debriefing and/or Guided Reflection

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Adult Learning Principles

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

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Adult Learning Principles

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

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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

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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

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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

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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

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Stages of Reflective Thinking

• Non reflectors
• Dont 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)

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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)

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Reflective Thinking

• Patient care varies with the nurses reflective
  abilities
• minimal reflective abilities illness oriented
  patient care
• reflective skills care based on the
  individualized needs of the client.
• Conway (1998)

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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).

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Barriers Outcomesof Reflective Thinking

• Barriers
• Previous learning
• Fixations
• Socialization (as a nurse)
• Organizational culture

• Outcomes
• Heightened self-confidence
• Empathy
• Understanding
• Better patient care

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Environment and Tools

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

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Setting the Ground Rules

• Confidential
• Review objectives and expectations
• Professional courtesy
• No interruptions
• Respect
• Supportive not judgmental
• Dont talk about anyone not present
• Positive before negative
• Listen

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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

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Discussion

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

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Faculty Role and Responsibilities

• Dual role facilitator and instructor
• Facilitator
• guide learner
• Instructor
• enhance understanding of deficiencies

Self-discovery
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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

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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?

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

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Debriefing Purpose

• Correct errors
• Identify different ways of handling event next
  time
• Encourage self-assessment
• Promote reflective thinking

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Debriefing - When

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

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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

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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?

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Debriefing Models

• Plus - Delta

Delta
Plus
Behaviors to improve on Include both what and how
Examples of good behaviors
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Debriefing Models

• Advocacy Inquiry
• I noticed .
• Im concerned
• I was wondering

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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

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Guided Reflection When

• Immediately after the experience

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Guided Reflection faculty (facilitators) 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

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Guided Reflection Models
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Gibbs (1988) Reflective Cycle
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Driscoll, 2000 The WHAT Model Of Reflection
WHAT? Describe the event
Experience
Purposeful reflection
New learning
SO WHAT? Analysis the event
Discover what learning emerges from
the reflection
NOW WHAT? Proposed action
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Johns, 1995, 1996(Based on Carpers 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.

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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.

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Johns,

• Reflexivity resolve the contradictions between
  what the practitioners 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.

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Deckers (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 patients room and repeated the scenario
   right now?

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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 (N28) Decker, 2007
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Additional 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 learners cultural background.

Decker, 2007
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Discussion

• As faculty how can we resolve these barriers?

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Summary 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
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Reflective Thinking

• Learning from reflection is not automatic
• It demands active involvement in clinical
  experience and guidance

64
References

• AACN, (2005). Faculty shortages in baccalaureate
  and graduate nursing programs
• Scope of the problem and strategies for
  expanding the supply. AACN Washington
• Boud, D., Koegh, R., Walker, D. (1985).
  Promoting reflection in learning A model.
• In D. Boud, R. Keogh D. Walker (Eds.),
  Reflection turning experience into
• learning (pp. 18 40). London Kogan Page.
• Clarke, S. P., Aiken, L. H. (2003). Failure to
  rescue Needless deaths are prime
• examples of the need for more nurses at the
  bedside. American Journal of Nursing,
• 103(9), 42-47.
• Del Bueno, D. (2005). A crisis in critical
  thinking Electronic version. Nursing
• Education Perspectives, 26(5), 278-282.
• Decker, S. (2007). Integrating guided reflection
  into simulated learning experiences. In
  Jeffries, P. R. (ed), Simulation in nursing
  education from conceptualization to evaluation.
  New York, NY National League for Nursing.
• Dreifuerst, K. T. (2009). The essential of
  debriefing in simulation learning A concept
  analysis. Nursing Education Perspectives, 30(2),
  109-114.

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References

• Finkelman, A. Kenner, C. (2007). Teaching IOM
  implications of the IOM report
• for nursing education, American Nurses
  Association, Silver Spring, Maryland.
• Glaze, J. (2002). Stages in coming to terms with
  reflection Student advanced nurse
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• 37(3), 265272.
• Jeffries, P. R. (2007) . Simulation in nursing
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• Johns, C. (1995). Framing learning through
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• Johns, C. (1996). Visualizing and realizing
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• Journal of Advanced Nursing, 24(6),
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• Mezirow, J. (1981). Transformative dimensions of
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References

• Murphy, J. I. (2004). Using focused reflection
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