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.