Sharon I Decker RN PhD ANEF FAAN Professor Director of Clinical Simulations Covenant Health System Endowed Chair in Simulation and Nursing Education The F Marie Hall Sim Life Center ID: 682983
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The Art and Science of Debriefing
Sharon I. Decker, RN, PhD,
ANEF, FAANProfessor, Director of Clinical SimulationsCovenant Health System Endowed Chair in Simulation and Nursing Education
The F. Marie Hall
Sim
Life
CenterSlide2
Objectives
Identify the goals of debriefing. Discuss the elements of debriefing that improve outcomes. Identify various approaches to debriefing. Discuss the process of debriefing.Slide3
Our students
“ It isn’t that they can’t see the solution. It is that they can’t see the problem.” G. K. Chesterton“They don’t know what they don’t know”ChallengeSlide4Slide5
“Better learning is associated with improved teaching techniques” [simulation]
Dunn, 2004Teaching techniques that are evidence based and applied appropriately facilitate successful learning (and patient outcomes). HypothesesSlide6
Experience alone does not guarantee learning nor clinical competence
Reflection promotes the transfer of experience to learning and knowledgeTherefore: Learning is dependent upon the integration of experience (simulation-based and patient centered) and reflection. Slide7
Conscious consideration of the meaning and implication of an action
Assimilation of:Knowledge (Concepts)SkillsAttitudes (Values & beliefs)With pre-existing knowledgeReflection: DefinedSlide8
Reflexio
(Latin)The act of bending backReflection: EtymologySlide9
A “wave motion or energy”
Reflectivity dependent on:Angles of incidents
Reflection: EtymologySlide10
A “wave motion or energy”
Reflectivity dependent on:Texture of the reflective surface Reflection: EtymologySlide11
A “wave motion or energy”
Reflectivity dependent on:Wavelength Reflection: EtymologySlide12
Reflection - Initiated through Questioning
…You lead me on by means of things I know, point to things that resemble them, and persuade me that I know things that I thought I had no knowledge of.”Socrates (B.C. 470-399)
(Quotes in Xenophon’s “Economics”)Slide13
Active, persistent, and careful considerationLearning is dependent upon integration of experience with reflection
Reflection promotes understanding of relationshipsDewey (1910, 1916, 1933)Slide14
Reflection-on-actionReflecting after – thinking through
Reflection-in-actionBeing aware Reflecting while doing“They ‘feel’ where the music is going and adjust their playing accordingly.” (pg. 30) Schön, 1987Slide15
Knowing-in-action (Expert) Professional knowledge
Skills competenceApplying theory while problem solvingResponds or “makes new sense” of uncertain, unique situationsSchönSlide16
“Think like a nurse”
Benner, Sutphen, Leonard, & Day, 2010Slide17
Kolb
Experiencing
(Concrete Experience)
Reflecting
(Reflective Observation)
Thinking
(Abstract Conceptualization)
Applying
(Active Experimentation)
Learning CycleSlide18
Kolb
Reflecting
(Reflective Observation)
Learning CycleSlide19
Barriers & Outcomesof Reflective Thinking
BarriersPrevious learningFixationsSocialization &Organizational cultureOutcomesHeightened self-confidenceEmpathyUnderstanding (Knowledge)Improved critical thinkingBetter patient careSlide20
Reflection
RequiresActive involvementRealist environmentAuthentic experienceAssistance (guidance)
Time to reflectSlide21
Reflection
Can be taught Learners expanded their repertoire of possible solutions Boyd & Fales
, 1983 Henderson & Johnson, 2002Slide22
Reflective Thinking
Learning from reflection is not automatic –It demands active involvement in clinical experience and guidanceSlide23
[The debriefing process] is the “heart and soul” of the simulated experience…
Rall, Manser, & Howard, 2000Slide24
Who should facilitate the debriefing?
Knowing how to debrief is as important as knowing how to create and initiate a simulated experience.Jeffries, 2005Slide25
What is the faculty’s role during the debriefing process?
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 FacilitatorSlide26
Difficulty developing reflection
Learner may have a distorted “view”Could lead to repeating mistakesLearners may only view the negative FixationsOutcome influenced by facilitator’s skillsBoud, Keough, & Walker, 1985; Boud, 2001;& Paget, 2001Need for a FacilitatorSlide27
If facilitators interject their feedback prematurely learners stop reflecting, lose confidence, and become dependent on faculty
Westberg & Jason, 2001 Caution Slide28
Facilitator’s Role and Responsibilities
Set expectations (outline the process)Facilitate according to level of engagementInclude “quiet” learnersIntegrate instructional pointsReinforce Identify deficienciesCorrect errorsSummarize & Review improvement strategies Slide29
Setting the Ground Rules
ConfidentialReview objectives and expectationsProfessional courtesyNo interruptionsRespectSupportive not judgmentalDon’t talk about anyone not presentPositive before negativeListenSlide30
Depends onThe objectives
The learnerThe facilitatorThe experienceTime allowed for the processRelationships between participantsDegree of FacilitationSlide31
High – “debrief themselves” [Critical Reflectors]
Intermediate – “assistance” needed to analyze the experience [Reflectors]Low – learners demonstrate little initiative [Non-Reflectors]Degree (Leveling) of FacilitationSlide32
The Environment
EnvironmentSafe – non-threatening, trustfulCircle – or modified according to objectivesPrivateTime Varies – equal to or longer then the scenarioSlide33
Audio-Visual Integration
Be proficient with the equipmentDo not show a segment unless it is to be discussedShow only 3 to 4 critical segments “This segment occurred … discuss what you were thinking as you…”Show the segmentPause – all the learner to self-critiqueSlide34
The Debriefing ProcessSlide35
Structure/ MethodsThe participants
The facilitator’s expertiseThe experienceThe impactThe recollectionThe timingSlide36
The Debriefing Process:
PurposeEncourage self/team analysisIdentify different ways of handling event next timeCorrect errorsPromote reflective thinkingSlide37
Debriefing
A process in which after an experience the learner is lead through a purposeful discussion related to the experienceLederman, 1992; Fanning & Gaba, 2007Slide38
Debriefing - When
During “In-Simulation” – “Simulation Suspended”Error in management or 30 seconds without actionFailure to perform a critical action Van Heukelon, Begaz, & Treat, 2010FrozenEmphasize teachingDefuse a deteriorating situationLimit embarrassmentDecker, Gore, & Feken, 2011AfterSlide39
Guided Reflection
The process that allows practitioners to uncover and expose thoughts, feelings and behaviorsAn active process of self-monitoring initiated by a state of doubt or puzzlement occurring during or after an experienceSlide40
Guided Reflection: When
Immediately after the experienceCan be integrated with debriefingSelf- Reflection – post experienceSlide41
The Debriefing Process: Organization
Beginning – Reactive phaseEmotional reactionsMiddle - AnalysisAnalysis and critiqueCorrect any errors not recognizedSummary - Summarize the simulationTranslation to practiceSlide42
Observers – PeersExplicit instructionsSet the ground rules
Needs to be guidedNeed a tool while observingDo not participate in the reactive phase During analysis – could be the third person in circular questioningTechniques: The Reflecting Team – Peer DebriefingSlide43
Socratic Questioning –
Guided questions – Strategically integrated “what if’s”, students find this difficultRequires active learningEncourages logic – making connectionsFacilitates critical thinkingIntegrated and/or during debrief Lambright, 1995; Schoeman, 1997TechniquesSlide44
Example
Socratic QuestioningWhat did you experience? Analyze how you performed overall.How would you change your performance?How can you apply knowledge and skills for this simulation to an actual patient care situation?Slide45
Techniques: Plus – Delta (Modified)
AlphaDelta (Based on standards)GammaExamples of good actionWhat we would like to changeHow we would change
What was the outcome when you initiated CUS?What could have occurred if CUE had not been initiated?Recognize performance gapStrategies to minimize performance gapSlide46
Phase Goal ActionsGather 25% Actively listen to participants Request narrative - Clarify
understand their perspectives “How did it make you feel?Analyze 50% Clarify - Facilitate reflection Report Observations Review events - Analyze Correct Ask probing questions “What were you thinking when…”Summarize 25% Facilitate identification Verify and Summarize Plan strategies “Describe two things you need to work on…” Techniques: The G.A.S. Method – Each Phase guided through questioningWISER http://www.wiser.pitt.edu/Slide47
Uses: reflection-in-action, reflection-on-action, and reflection-beyond-action
Six phases – Engaging, Exploring, Explaining, Elaborating, Evaluating, and ExtendingFocuses on learning Uses concept mappingTechniques: Debriefing for Meaningful Learning© (DML)Slide48
Ask how one participant thinks another participant felt in a situationExample: “Jackie, how do you think Joe felt when you didn’t listen to his suggestions during the simulation?”
OrAsk a third person to discuss a behavior that occurred between other participantsExample: “Jenny, what did you observe related to the interaction between Jackie and Joe?”Techniques: Circular QuestioningSlide49
“Debriefing with Good Judgment” – (Advocacy-Inquiry)
Techniques (Harvard)
Debriefing leads to new framesDebriefing changes later actionshttp://www.harvardmedsim.orgSlide50
Advocacy – Inquiry“I noticed
….” “you did not double-check the dose of the medication. Without the double –check”“I’m concerned…” “that the patient is at more risk of getting the wrong dose.”“I was wondering…” “what was on your mind at the time?”ExampleSlide51
Depends on learners and objectives[Example]
Review recorded performance (A-V)Peer DebriefSelf-Debrief “self-assessment” Debrief checklistWritten JournalWeb-basedCombining TechniquesSlide52
Research needed
“how to promote reflection”“when and how often”“what are the most effective approaches”“whom should be included in the process”“how to structure – what tools/techniques”Measurement tool
Debriefing Assessment for Simulation in Healthcare (DASH)http://www.harvardmedsim.org.debriefing-asssessment-simualtion-healthcare.phpMoving Forward: Uncover the Evidence Slide53
SSH: Certification and Accreditation
Evaluate educational effectiveness Assessment of debriefing - DASH Meeting of educational objectivesScenariosVideos of simulations and debriefingSlide54
INACSL: Standards
All simulated experiences should include a planned debriefing session aimed toward promoting reflective thinkingGuidelines and toolbox being developedSlide55
References
WebsitesSimulation Innovation Resource Center, National League for Nurses http://sirc.nln.org/TeamSTEPPS
available at http://teamstepps.ahrq.gov/QSEN Teaching Strategies incorporating simulation available at http://www.qsen.org/view-strategies.phpWorld Health Organization: Patient Safety Tool Kit available at
http
://www.who.int/patientsafety/education/en
/Slide56
References
WebsitesArmy’s After-Action Review – Summary: available at http://www.au.af.mil/au/awc/awcgate/army/tc_25-20/chap1.htm
http://www.wpahs.org/education/star-center/course-catalog/star-courses/debriefing-toolshttp://collaborate.uw.edu/educators-toolkit/debriefing-tools.htmlSlide57
References
Debriefing Guide for Facilitatorsfurcs.flinders.edu.au/.../CHSA%20sim%20toolkit/...
DASHhttp://www.wpahs.org/sites/default/files/file/D11DASH-handbook2010FinalRev2.pdfThe Observational Structured Assessment of Debriefing Toolhttp://www1.imperial.ac.uk/resources/CFE7DECB-8FE7-437C-8DAA-6AB6C5958D66/debriefingosadtool.pdf