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The Role of Debriefing and Guided Reflection in Simulation

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Title: 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
    (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
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
Experience alone does not guarantee learning
Need the integration of reflection (Boud,
Keogh, Walker, 1985)
  • Simulation
  • Patient Care Experience
  • Debriefing and/or Guided Reflection

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
  • 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)

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 nurses 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 Outcomes of 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
  • Dont 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
Behaviors to improve on Include both what and how
Examples of good behaviors
45
Debriefing Models
  • Advocacy Inquiry
  • I noticed .
  • Im 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

51
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

52
Guided Reflection Models
53
Gibbs (1988) Reflective Cycle
54
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
55
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.

56
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.

57
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.

58
Deckers (Based on Johns Work)
  • Talk to me about the problem your patient was
    having
  • What was your main goal during this simulation?
  • Tell me what influenced your actions during the
    scenario.
  • Talk to me about how this experience made you
    feel and how satisfied you are with the actions
    you initiated?
  • Talk to me about how your personal values and
    beliefs influenced your actions during this
    experience.
  • Talk to me about the knowledge and skills you
    have that helped you provide patient care during
    this simulated experience.
  • Talk to me about experiences you have had that
    influenced what you did during this scenario.
  • What would you do different if we went back into
    the patients room and repeated the scenario
    right now?

59
Factors Identified by Student Groups as
Affecting Critical and Reflective Thinking
During a Simulated Learning Experience
60
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
61
Discussion
  • As faculty how can we resolve these barriers?

62
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
63
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.

65
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
  • practitioners perceptions of their
    reflective journeys. Journal of Advanced Nursing,
  • 37(3), 265272.
  • Jeffries, P. R. (2007) . Simulation in nursing
    education form conceptualization to
  • evaluation. New York, NY National League
    for Nursing.
  • Johns, C. (1995). Framing learning through
    reflection within Carpers fundamental
  • ways of knowing in nursing. Journal of
    Advanced Nursing, 22(2), 226234.
  • Johns, C. (1996). Visualizing and realizing
    caring in practice through guided reflection.
  • Journal of Advanced Nursing, 24(6),
    11351143.
  • Mezirow, J. (1981). Transformative dimensions of
    adult learning. San Francisco
  • Jossey-Bass.

66
References
  • Murphy, J. I. (2004). Using focused reflection
    and articulation to promote clinical
  • reasoning An evidence-based teaching
    strategy. Nursing and Health Care
  • Perspectives, Nursing and Healthcare, 25(5),
    226231.
  • National League for Nursing (NLN). (2005, May).
    Position statement Transforming
  • nursing education. Retrieved July 9, 2006,
    from
  • http//www.nln/aboutnln/PositionStatements/tr
    ansforming0520005.pdf
  • Nehring, W. M. Lashley, F. R. (2010).
    High-Fidelity Patient Simulation in Nursing
    Education. Sudbury, MA Jones and Barlett
    Publishers.
  • Paget, T. (2001). Reflective practice and
    clinical outcomes Practitioners views on how
  • reflective practice has influenced their
    clinical practice. Journal of Clinical Nursing,
  • 10(2), 204-214.
  • Wong, F. K. Y., Kember, D., Chung, L. Y .F.,
    Yan, L. (1995). Assessing the level of
  • student reflection from reflective journals.
    Journal of Advanced Nursing, 22, 48-57.
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