Until We Reflect"

Until We Reflect"

The F. Marie Hall SimLife Center The Art and Science of Debriefing Sharon I. Decker, RN, PhD, ANEF, FAAN Professor, Director of Clinical Simulations Covenant Health System Endowed Chair in Simulation and Nursing Education

Objectives Identify the goals of debriefing. Discuss the elements of debriefing that improve outcomes. Identify various approaches to debriefing.

Discuss the process of debriefing. Challenge Our students It isnt that they cant see the solution. It is that they cant see the problem. G. K. Chesterton They dont know what they dont know

Hypotheses Better learning is associated with improved teaching techniques [simulation] Dunn, 2004 Teaching techniques that are evidence based and applied appropriately facilitate successful learning (and patient outcomes). Experience

alone does not guarantee learning nor clinical competence Reflection promotes the transfer of experience to learning and knowledge Therefore: Learning is dependent upon the integration

of experience (simulation-based and patient centered) and Reflection: Defined Conscious consideration of the meaning and implication of an action Assimilation of: Knowledge (Concepts) Skills Attitudes (Values & beliefs) With pre-existing knowledge

Reflection: Etymology Reflexio (Latin) The act of bending back Reflection: Etymology A wave motion or energy Reflectivity dependent on: Angles of

incidents Reflection: Etymology A wave motion or energy Reflectivity dependent on: Texture of the reflective surface Reflection: Etymology A wave

motion or energy Reflectivity dependent on: Wavelength Socrates (B.C. 470-399) 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. (Quotes in Xenophons Economics) Dewey (1910, 1916, 1933) Active, persistent, and careful consideration Learning is dependent upon integration of experience with reflection

Reflection promotes understanding of relationships Schn, 1987 Reflection-on-action Reflecting after thinking through Reflection-in-action Being aware

Reflecting while doing They feel where the music is going and adjust their playing accordingly. (pg. 30) Schn Knowing-in-action (Expert) Professional knowledge Skills competence

Applying theory while problem solving Responds or makes new sense of uncertain, unique situations Benner, Sutphen, Leonard, & Day, 2010 Think like a nurse

Kolb Reflecting (Reflective Observation) Experiencing (Concrete Experience) Learning Cycle Thinking Applying (Active Experimentation)

(Abstract Conceptualization) Kolb Reflecting (Reflective Observation) Learning Cycle Barriers & Outcomes of Reflective Thinking Barriers

Previous learning Fixations Socialization & Organizational culture Outcomes Heightened selfconfidence Empathy Understanding (Knowledge) Improved critical

thinking Better patient care Reflection Requires Active involvement Realist environment Authentic experience Assistance (guidance) Time to reflect Reflection Can

be taught Learners expanded their repertoire of possible solutions Boyd & Fales, 1983 Henderson & Johnson, 2002 Reflective Thinking Learning from reflection is not automatic

It demands active involvement in clinical experience and guidance [The debriefing process] is the heart and soul of the simulated experience Rall, Manser, & Howard, 2000

Who should facilitate the debriefing? Knowing how to debrief is as important as knowing how to create and initiate a simulated experience. Jeffries, 2005 What is the facultys role during the debriefing process? 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 Need for a Facilitator Difficulty Learner developing reflection may have a distorted

view Could lead to repeating mistakes Learners may only view the negative Fixations Outcome influenced by facilitators skills Caution If facilitators interject their feedback prematurely learners stop reflecting,

lose confidence, and become dependent on faculty Westberg & Jason, 2001 Facilitators Role and Responsibilities Set expectations (outline the process) Facilitate according to level of engagement Include quiet learners Integrate instructional points Reinforce Identify deficiencies

Correct errors Summarize & Review improvement strategies 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 Degree of Facilitation Depends on The objectives The learner The facilitator The experience Time allowed for the process Relationships between participants

Degree (Leveling) of Facilitation High debrief themselves [Critical Reflectors] Intermediate assistance needed to analyze the experience [Reflectors] Low learners demonstrate little initiative [Non-Reflectors] The Environment Environment

Safe non-threatening, trustful Circle or modified according to objectives Private Time Varies equal to or longer then the scenario 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 This segment occurred discuss what you were thinking as you Show the segment Pause all the learner to self-critique The Debriefing Process Structure/ Methods The The The

The participants facilitators expertise experience impact The recollection The timing The Debriefing Process: Purpose

Encourage self/team analysis Identify different ways of handling event next time Correct errors

Promote reflective thinking 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 - When

During In-Simulation Simulation Suspended Error in management or 30 seconds without action Failure to perform a critical action Van Heukelon, Begaz, & Treat, 2010 Frozen Emphasize teaching Defuse a deteriorating situation Limit embarrassment Decker, Gore, & Feken, 2011

After 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: When Immediately after the experience Can be integrated with debriefing Self- Reflection post experience The Debriefing Process: Organization

Beginning Reactive phase Emotional reactions Middle - Analysis Analysis and critique Correct any errors not recognized Summary Summarize the simulation

Translation to practice Techniques: The Reflecting Team Peer Debriefing Observers Peers Explicit instructions Set the ground rules Needs to be guided Need a tool while observing Do not participate in the reactive phase During analysis could be the third person in circular questioning

Techniques Socratic Questioning Guided questions Strategically integrated what ifs, students find this difficult Requires active learning Encourages logic making connections Facilitates critical thinking Integrated and/or during debrief Lambright, 1995; Schoeman,

1997 Example Socratic Questioning What 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? Techniques: Plus Delta

(Modified) Alpha Delta (Based Gamma on standards) Examples of good action What we would like to change How we would

change What was the outcome What could have occurred when you initiated if CUE had not been CUS? initiated? Recognize performance gap Strategies to minimize performance gap

Techniques: The G.A.S. Method Each Phase guided through questioning Phase Gather Goal Actions 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

WISER http://www.wiser.pitt.edu/ Techniques: Debriefing for Meaningful Learning (DML) Uses: reflection-in-action, reflection-on-action, and reflection-beyond-action Six phases Engaging, Exploring, Explaining, Elaborating, Evaluating, and Extending Focuses on learning Uses concept mapping

Techniques: Circular Questioning Ask how one participant thinks another participant felt in a situation Example: Jackie, how do you think Joe felt when you didnt listen to his suggestions during the simulation? Or Ask a third person to discuss a behavior that occurred between other participants

Example: Jenny, what did you observe related to the interaction between Jackie and Joe? Techniques (Harvard) Debriefing with Good Judgment (Advocacy-Inquiry) Debriefing leads to new frames Debriefing changes

later actions http://www.harvardmedsim.org Example Advocacy Inquiry I noticed . you did not double-check the dose of the medication. Without the double check Im concerned that the patient is at more risk of getting the wrong dose.

I was wondering what was on your mind at the time? Combining Techniques Depends on learners and objectives [Example] Review recorded performance (A-V) Peer Debrief Self-Debrief self-assessment

Debrief checklist Written Journal Web-based Moving Forward: Uncover the Evidence 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.debriefingasssessment-simualtion-healthcare.php SSH: Certification and Accreditation Evaluate educational effectiveness Assessment of debriefing - DASH Meeting of educational objectives Scenarios Videos of simulations and debriefing

INACSL: Standards All simulated experiences should include a planned debriefing session aimed toward promoting reflective thinking Guidelines and toolbox being developed References Websites Simulation 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.php World Health Organization: Patient Safety Tool Kit available at http ://www.who.int/patientsafety/education/en/

References Websites Armys 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-tools

http://collaborate.uw.edu/educators-toolkit/debriefing-tools.html References Debriefing Guide for Facilitators furcs.flinders.edu.au/.../CHSA%20sim%20toolkit/... DASH http://www.wpahs.org/sites/default/files/file/D11DASH-handbook2010FinalRev2.pdf The Observational Structured Assessment of Debriefing Tool http://www1.imperial.ac.uk/resources/CFE7DECB-8FE7-437C-8DAA-6AB6C5958D66/ debriefingosadtool.pdf

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