The Role of Debriefing and Guided Reflection in Simulation

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

Objectives

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

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

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

How have these changes impacted-

how we deliver education?

competencies required for our discipline?

Health Educators’: Challenge #1

Introduction

Challenges for the Health Educator

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

IOM, Crossing the Quality Chasm (2001)

Federal 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 #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:

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 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 “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 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:

For example: United States Medical Licensure ExaminationAssesses 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:

National Board for Respiratory CareIncludes 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 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 Future

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

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)

Adult Learning Principles

Diverse Learning StylesVisual (realism, fidelity of the environment)

Auditory (verbal responses)

Tactile (hear and lung sounds)

Kinesthetic (handling equipment)

Adult Learning Principles

Constructivism

Learning = process of constructing meaning

Educator functions as a collaborative facilitator

Includes experiential learning

Active engagement

Reflective thought

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

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

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

Reflection

SchÖnReflection-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 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 Thinking

Enhances learning from experienceHelps expand clinical knowledgePromotes reflective practiceImproves clinical judgment

Glaze, J. E. (2001)

Paget, T. (2001)Murphy, J. I. (2004)

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)

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).

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

Setting the Ground Rules

ConfidentialReview objectives and expectationsProfessional courtesy No interruptions Respect

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

Listen

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

Discussion

Do you include audio-visual segment during each simulation?

When would they be appropriate?

Thing to think about:Confidentiality formsArchiving of materials

Faculty Role and Responsibilities

Dual role – facilitator and instructor

Facilitator

guide learner

Instructor

enhance understanding of “deficiencies”

Self-discovery

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

Faculty Role and Responsibilities

Give your analysis lastKeep the discussion “learner centered”Be an active listenerUse silence and pausesUse questioning – if appropriate to

encourage discussionsidentify issuesexplore 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

Debriefing

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

Debriefing: Purpose

Correct errors

Identify different ways of handling event next time

Encourage self-assessment

Promote reflective thinking

Debriefing - When

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

After

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

Debriefing Models

QuestioningWhat 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 Models

Plus - Delta

Plus + Delta –

Behaviors to improve onInclude both what and how

Examples of good behaviors

Debriefing Models

Advocacy – Inquiry “I noticed ….”

“I’m concerned…”

“I was wondering…”

Debriefing

Summary

Correct any errors

Video for discussion

Guided Reflection

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

Guided Reflection: Purpose

Promotes insightfulness

Leads to discovery of new knowledge

New knowledge – to be applied in future situations

Guided Reflection: When

Immediately after the experience

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: Models

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)

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,

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,

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)

1. Talk to me about the problem your patient was having2. 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 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

Discussion

As faculty how can we resolve these barriers?

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

Reflective Thinking

Learning from reflection is not

automatic –

It demands active involvement in clinical

experience and guidance

References

AACN, (2005). Faculty shortages in baccalaureate and graduate nursing programs: Scope of the problem and strategies for expanding the supply. AACN: WashingtonBoud, 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.

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), 265–272.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 Carper’s fundamental ways of knowing in nursing. Journal of Advanced Nursing, 22(2), 226–234. Johns, C. (1996). Visualizing and realizing caring in practice through guided reflection. Journal of Advanced Nursing, 24(6), 1135–1143.Mezirow, J. (1981). Transformative dimensions of adult learning. San Francisco: Jossey-Bass.

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), 226–231.National League for Nursing (NLN). (2005, May). Position statement: Transforming nursing education. Retrieved July 9, 2006, from http://www.nln/aboutnln/PositionStatements/transforming0520005.pdfNehring, 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.