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Investigating novice doctors’ reflections in debriefings after simulation scenarios
Abstract
Background:
Debriefing is pivotal to the simulation learning process, and the reflection that it aims to foster is fundamental in experiential learning. Despite its importance, essential aspects of debriefing remain unclear.
Study objective:
To investigate reflection in debriefings by assessing participants' reflection levels in discussions of leader/follower-ship or role distribution and compare occurrences of high reflection with those of lower reflection.
Methods:
The data consisted of videos from 38 debriefings with 10 debriefers from the Danish Institute of Medical Simulation. An adapted framework of reflection levels was used for the analysis. A comparison was made between debriefers' utterances across occurrences of higher and lower reflection.
Results:
Participants reached only lower reflection levels. Of five reflection levels, the second was reached the most frequently and the third was the highest reached. No salient differences were found in debriefers' utterances across occurrences of higher and lower reflection.
Conclusion:
Participants' reflection levels were low in this cohort of novice doctors training leadership skills in acute situations. However, the desired reflection should be appropriated to the given context. The rating of reflection levels is a promising approach to analyze reflection in conversation in experience-based learning situations.
... 22 23 39 40 As a consequence, engagement in and organisational and educational effectiveness of debriefing may suffer, reducing the capability of healthcare teams to learn and improve patient care. [41][42][43][44][45] The latter might be exacerbated by the recently discussed eschewal of trained debriefers in favour of having teams debrief themselves. 10 41 42 Targeted faculty development is required to help clinicians and educators to improve their debriefing skills. ...
... 49 Empirically, the debriefing process is a black box; very few studies have examined actual debriefing conversations and how differences in debriefers' communication influence participants' outcomes. 10 44 45 50 51 In particular, systematic analysis of interaction among debriefers and participants-how actions of debriefers are related to actions of participants-are rare. As a consequence, there is very limited empirical, actionable knowledge on optimal debriefing facilitation for high-quality reflection. ...
Background
Debriefings help teams learn quickly and treat patients safely. However, many clinicians and educators report to struggle with leading debriefings. Little empirical knowledge on optimal debriefing processes is available. The aim of the study was to evaluate the potential of specific types of debriefer communication to trigger participants’ reflection in debriefings.
Methods
In this prospective observational, microanalytic interaction analysis study, we observed clinicians while they participated in healthcare team debriefings following three high-risk anaesthetic scenarios during simulation-based team training. Using the video-recorded debriefings and INTERACT coding software, we applied timed, event-based coding with DE-CODE, a coding scheme for assessing debriefing interactions. We used lag sequential analysis to explore the relationship between what debriefers and participants said. We hypothesised that combining advocacy (ie, stating an observation followed by an opinion) with an open-ended question would be associated with participants’ verbalisation of a mental model as a particular form of reflection.
Results
The 50 debriefings with overall 114 participants had a mean duration of 49.35 min (SD=8.89 min) and included 18 486 behavioural transitions. We detected significant behavioural linkages from debriefers’ observation to debriefers’ opinion (z=9.85, p<0.001), from opinion to debriefers’ open-ended question (z=9.52, p<0.001) and from open-ended question to participants’ mental model (z=7.41, p<0.001), supporting our hypothesis. Furthermore, participants shared mental models after debriefers paraphrased their statements and asked specific questions but not after debriefers appreciated their actions without asking any follow-up questions. Participants also triggered reflection among themselves, particularly by sharing personal anecdotes.
Conclusion
When debriefers pair their observations and opinions with open-ended questions, paraphrase participants’ statements and ask specific questions, they help participants reflect during debriefings.
... Being able to reflect in the middle of a situation has been suggested to be a critical skill for nursing practice, therefore, undergraduate nursing simulation facilitators need to be able to identify and support students to reflect-in-action (Mulli et al., 2021). Benefits to reflection-inaction include learners performing new actions; being able to adapt and improvise; gaining understanding or new knowledge; feeling secure; and increased self-confidence (Clapper and Leighton, 2019;Hughes and Scholtz, 2015;Kihlgren et al., 2014;McMullen et al., 2016). Despite this, there has been little research on how undergraduate nursing simulation facilitators identify and support reflection-in-action during high-fidelity simulation. ...
... Lastly, participants identified a number of benefits to students reflecting-in-action, specifically, that it assists in collaborative learning, builds confidence, demonstrates and builds critical thinking skills, and embeds reflection into everyday practice. The literature finds that when students can reflect-in-action they gain new knowledge (McMullen et al., 2016;Mulli et al., 2021); are able to improvise and adapt (Kihlgren et al., 2014;Mulli et al., 2021); and perform new actions (Hughes and Scholtz, 2015;Mulli et al., 2021). These learners feel certain, secure, and have a sense of self-improvement (Mulli et al., 2021). ...
Background
Reflective practice is an essential step to learning in high-fidelity simulation, yet, reflection-in-action is an often overlooked yet important opportunity to support student learning.
Objectives
To explore and describe the lived experience of undergraduate nursing simulation facilitators use of reflection-in-action during high-fidelity simulation.
Design
A descriptive phenomenological study.
Setting
A western Canadian province.
Participants
Undergraduate nursing simulation facilitators with experience in nursing education and simulation facilitation.
Methods
We conducted 11 semi-structured interviews and utilized Colaizzi's seven step process of analysis to discover the essence of undergraduate nursing simulation facilitators use of reflection-in-action during high-fidelity simulation.
Results
Simulation facilitators were able to identify reflection-in-action during high-fidelity simulation when students paused, collaborated, shared their thinking aloud, and changed their course of action. Barriers to reflection-in-action included learner fear and anxiety, poor simulation design, and inadequately prepared students and facilitators. Simulation facilitators supported reflection-in-action through prebriefing, facilitator curiosity, and providing cue, prompts, and facilitated paused. Some of the noted benefits to reflection-in-action include promoting collaborative learning, building confidence and critical thinking, and embedding reflection into practice.
Conclusions
The insights from this research can be used to guide reflection-in-action strategy development and future research in high-fidelity simulation.
... This is not the case for implicit debriefing. Kihlgren et al. (2014) observed similarities in their investigations into reflection in debriefings by assessing participants' reflection levels using a framework of reflection levels developed by Fleck (2012). The participants' reflection levels were low in the cohort of novice doctors. ...
... L'utilisation de la simulation se situe donc, pour les apprenants expérimentés, plus dans une dynamique d'entrainement (training) que d'apprentissage (learning). Pour ces derniers, elle permet surtout d'optimiser leurs performances en lien avec des connaissances déclaratives et procédurales déjà acquises (processus de répétition qui favorise l'automatisation) alors que pour les novices, elle permet l'acquisition de nouvelles connaissances et de nouveaux automatismes (processus d'acquisition).Sur un plan purement pragmatique, nos résultats montrent qu'il ne s'agit pas de rejeter systématiquement une approche réflexive du débriefing au profit d'une approche explicite mais que le choix, de l'une ou de l'autre, doit être guidé par les caractéristiques des apprenants, en particulier leur niveau d'expertise40,41 . Certains auteurs voient d'ailleurs le débriefing comme pouvant évoluer sur un continuum allant d'un débriefing directif à facilitation minimale centré sur le formateur à un débriefing réflexif à facilitation élevée centré sur l'apprenant42 . ...
La simulation est devenue un outil pédagogique incontournable dans la formation et le développement des professionnels de santé tant sur un plan individuel que sur le plan du travail en équipe. Cependant, face à l’utilisation croissante de la simulation pour les formations en santé, nombre de questions persistent quant aux mécanismes en jeu dans l’apprentissage par simulation ainsi qu’aux modalités pédagogiques à mettre en œuvre pour optimiser l’efficacité de ces formations. L’objectif de ce travail de thèse vise d’abord une meilleure compréhension du processus d’apprentissage expérientiel à l’œuvre lors d’une session d’apprentissage par simulation pour ensuite proposer une structuration des phases du débriefing susceptibles de favoriser l’acquisition de nouvelles connaissances déclaratives et procédurales. Une première étude a permis de montrer l’efficacité de la mise en place de situations simulées lors des formations aux gestes et soins d’urgence. Une deuxième étude a confirmé l’intérêt d’un programme de simulation construit selon les principes d’apprentissage expérientiel de Kolb (1984) sur les réactions, apprentissages et comportements de soignants expérimentés travaillant en équipes pluri-professionnelles de structure mobile d’urgence et de réanimation (SMUR). Ce travail s’est ensuite centré sur la place accordée au débriefing dans l’apprentissage par simulation. Une troisième étude a précisé la place du débriefing dans l’évolution du sentiment d’efficacité personnelle des apprenants et, dans la lignée des travaux sur l’enseignement explicite, a montré la supériorité des approches structurées et explicites du débriefing par rapport aux approches implicites et réflexives pour l’apprentissage de connaissances déclaratives chez les apprenants novices (étudiants infirmiers). Une quatrième étude a ensuite montré que, pour des apprenants expérimentés en équipes pluri-professionnelles de service d’urgence, le débriefing explicite s’avérait aussi efficace qu’un débriefing réflexif sur l’évolution des connaissances déclaratives, du sentiment d’efficacité personnelle ainsi que sur les modifications comportementales. Sur un plan pragmatique, les résultats de ce travail apportent des éléments pour la mise en œuvre d’une session d’apprentissage par simulation en santé et notamment sur la manière de structurer les différentes séquences de débriefing selon le public considéré.
... We would like to set the focus on a micro level and point out a potential problemthe problem of conceptual clarity of the discussions during debriefings. A previous study showed that the depth of reflection during debriefings may not be as anticipated (Kihlgren et al. 2015). Discussions in debriefings investigated were somewhat superficial. ...
... Debriefing practices within these phases vary considerably, and they might have different names in the different phases: the facilitator might tell the participants what they did well or not so well or he/she might ask them to describe their own view around these issues; the leader during the simulation scenario might be in the center of the discussion or he/she might choose to listen to what the team members have to say; the content focus might shift throughout, giving more weight to certain discussions over others; the team might seek consensus around certain aspects or nurture diversity of views. Several papers try to describe debriefing practice in more detail, for example, who speaks with whom about what in a debriefing ), how debriefing interactions unfold in different cultures (Ulmer et al. 2018), how people interact in debriefings with each other and with the material they have available (Nystrom et al. 2016), how facilitators' questions are related to the discussions and reflections during debriefings (Kihlgren et al. 2015;Husebo et al. 2013), if and how video is used during debriefings (Johansson et al. 2017), and what kind of thought and emotions facilitators might experience during debriefing (Rudolph et al. 2013). ...
... Risk of shallow or short-sighted argumentation, single rather than double-loop learning, and low levels of reflection and limited effectiveness of feedback (Argyris, 2002;Homayounfar et al., 2015;Kihlgren et al., 2015;Hughes et al., 2016;Boos and Sommer, 2018). ...
... The conceptual work has focused on how to conduct debriefings (Rudolph et al., 2007(Rudolph et al., , 2008(Rudolph et al., , 2013(Rudolph et al., , 2014Cheng et al., 2014;Eppich et al., 2015Eppich et al., , 2016Kessler et al., 2015;Sawyer et al., 2016a;Cheng et al., 2017;Kolbe and Rudolph, 2018;Endacott et al., 2019). The empirical work has focused on communication in debriefings, albeit rather unsystematically and rarely applying rigorous team science methodology (e.g., Husebø et al., 2013;Kihlgren et al., 2015). Consequences of previous research on teamwork in debriefings include valuable knowledge on debriefing effectiveness and on macro-level debriefing process on the one hand and very limited actionable knowledge on optimal debriefing interaction processes and facilitation for high quality reflection on the other hand. ...
In this manuscript we discuss the consequences of methodological choices when studying team processes "in the wild." We chose teams in healthcare as the application because teamwork cannot only save lives but the processes constituting effective teamwork in healthcare are prototypical for teamwork as they range from decision-making (e.g., in multidisciplinary decision-making boards in cancer care) to leadership and coordination (e.g., in fast-paced, acute-care settings in trauma, surgery and anesthesia) to reflection and learning (e.g., in post-event clinical debriefings). We draw upon recently emphasized critique that much empirical team research has focused on describing team states rather than investigating how team processes dynamically unfurl over time and how these dynamics predict team outcomes. This focus on statics instead of dynamics limits the gain of applicable knowledge on team functioning in organizations. We first describe three examples from healthcare that reflect the importance, scope, and challenges of teamwork: multidisciplinary decision-making boards, fast-paced, acute care settings, and post-event clinical team debriefings. Second, we put the methodological approaches of how teamwork in these representative examples has mostly been studied centerstage (i.e., using mainly surveys, database reviews, and rating tools) and highlight how the resulting findings provide only limited insights into the actual team processes and the quality thereof, leaving little room for identifying and targeting success factors. Third, we discuss how methodical approaches that take dynamics into account (i.e., event- and time-based behavior observation and micro-level coding, social sensor-based measurement) would contribute to the science of teams by providing actionable knowledge about interaction processes of successful teamwork.
... Discussions of good performance should address all the context layers described above: What are the resources and conditions that enhance and enable the team's ability to adapt? This is not an easy task and requires the facilitator to stimulate deep reflections about what is often taken for granted [77]. Simulation debriefings offer many of the elements that make this discussion relevant: a trained facilitator, to help participants to relate their actions to safety and human-factors theories in addition to the clinical aspects; video recordings offer an outside view; protected time and space to engage in meaningful discussions; and (hopefully) a working agreement (ground rules) that enables the necessary trust for a discussion that analyses the "taken-for-granted" [24]. ...
... The approach we suggest here requires sufficient time to discuss the activities and thoughts of the participants during the scenario. Studies show that current debriefing practice may not reach this deep reflective level consistently; too little time for a large number of topics might be one of the obstacles for deep reflections [77]. It may be enough to focus on a few key moments of the scenario to create the habit and reflexive mindset of learning from success, which participants can then carry into their daily practice [44]. ...
Simulation is traditionally used to reduce errors and their negative consequences. But according to modern safety theories, this focus overlooks the learning potential of the positive performance, which is much more common than errors. Therefore, a supplementary approach to simulation is needed to unfold its full potential. In our commentary, we describe the learning from success (LFS) approach to simulation and debriefing. Drawing on several theoretical frameworks, we suggest supplementing the widespread deficit-oriented, corrective approach to simulation with an approach that focusses on systematically understanding how good performance is produced in frequent (mundane) simulation scenarios. We advocate to investigate and optimize human activity based on the connected layers of any setting: the embodied competences of the healthcare professionals, the social and organizational rules that guide their actions, and the material aspects of the setting. We discuss implications of these theoretical perspectives for the design and conduct of simulation scenarios, post-simulation debriefings, and faculty development programs.
... Participants' emotional reactions, actions and interactions in the scenario are often brought up as topics. The debriefing phase is viewed as being critical for the participants' learning in a simulation [5][6][7][8][9]. Fanning and Gaba [10] clarify the bridging function that debriefing serves between experiencing an event and learning from it. ...
... The findings of this study support previous research [11][12][13] in that the instructor's role in facilitating the group process and involving the individual in the debriefing is found to be important. Kihlgren et al. [8] adopted a previously developed framework for analysing levels of reflection and applied the framework on utterances in 38 debriefing sessions with 10 instructors conducting the debriefing. The findings showed that the participants' reflections levels were usually low, and that no differences were found in the debriefers' utterances across occurrences of higher and lower reflection. ...
Background
The debriefing phase is an important feature of simulation activities for learning. This study applies a sociomaterial perspective on debriefing in interprofessional simulation with medical and nursing students. Sociomaterial perspectives are increasingly being used in order to understand professional practice and learning in new ways, conceptualising professional practice as being embodied, relational and situated in sociomaterial relations. The aim of the study is to explore how debriefing is carried out as a practice supporting students’ interprofessional learning.
Methods
Eighteen debriefing sessions following interprofessional full-scale manikin-based simulation with nursing and medical students from two different universities were video-recorded and analysed collaboratively by a team of researchers, applying a structured scheme for constant comparative analysis.
Results
The findings show how debriefing is intertwined with, and shaped by social and material relationships. Two patterns of enacting debriefing emerged. Debriefing as algorithm was enacted as a protocol-based, closed inquiry approach. Debriefing as laissez-faire was enacted as a loosely structured collegial conversation with an open inquiry approach.
Conclusion
The findings indicate that neither an imposed structure of the debriefing, nor the lack of structure assured interprofessional collaboration to emerge as a salient topic for reflection, even though that was an explicit learning objective for the simulation.
... The importance of debriefing to promote reflection is accepted as a cornerstone of simulation-based education (Fanning & Gaba, 2007;Cheng et al., 2014;Dufrene & Young, 2014;Levett-Jones & Lapkin, 2014). Theory supporting reflection is not well studied, and there is insufficient evidence to support any single debriefing strategy providing better or best learning outcomes (Husebø, Dieckmann, Rystedt, Søreide, & Friberg, 2013;Dufrene & Young, 2014;Kihlgren, Spanager, & Dieckmann, 2014). Gibbs's reflective cycle (Gibbs, 1988) has previously been used to support the process of reflection in midwifery practice (Gnash, 2009), interprofessional patient-centered care and ethical dilemmas (Jones, 2007;Burzotta & Noble, 2011), emergency care (Powley, 2013), and nursing, physiotherapy, and dental hygiene education (Wilding, 2008;Maloney, Tai, Lo, Molloy, & Ilic, 2013;Wallace, Blinkhorn, & Blinkhorn, 2013). ...
... The learning that results from superficial reflection is likely to be without depth (Moon, 2007). Similarly, Kihlgren et al. (2014) support the view that Gibbs's reflective cycle does foster deeper reflection in the same way as the model described by Fleck (2012). Curiously, Gibbs does not define either reflection or analysis. ...
Reflection is important for learning in simulation-based education (SBE). The importance of debriefing to promote reflection is accepted as a cornerstone of SBE. Gibbs's reflective cycle is a theoretical framework comprised of six stages and can be used during structured debriefing to guide reflection. The aim of the article was to provide an overview of Gibbs's reflective cycle and its application to debriefing during SBE.
... Participants in the feedback conversations were two female and four male trainees; one female and one male trainee participated twice. The median age of the participants was 31 (31)(32)(33) and their positions were introductory year to specialty training year 1-3. Participants had performed median two (0-30) independent operations of the same type, for which they received feedback, and median nine (1-30) supervised operations of the same kind. ...
... 27 This is also in line with a study on reflection levels. 32 Considering that simulation courses provide protected time and a structured framework for feedback, it is understandable that the picture in clinical practice is no better. ...
This study aimed to explore the content of conversations, feedback style, and perceived usefulness of feedback to trainee surgeons when conversations were stimulated by a tool for assessing surgeons' non-technical skills.
Trainee surgeons and their supervisors used the Non-Technical Skills for Surgeons in Denmark tool to stimulate feedback conversations. Audio recordings of post-operation feedback conversations were collected. Trainees and supervisors provided questionnaire responses on the usefulness and comprehensiveness of the feedback. The feedback conversations were qualitatively analyzed for content and feedback style. Usefulness was investigated using a scale from 1 to 5 and written comments were qualitatively analyzed.
Six trainees and six supervisors participated in eight feedback conversations. Eighty questionnaires (response rate 83 percent) were collected from 13 trainees and 12 supervisors. Conversations lasted median eight (2-15) minutes. Supervisors used the elements and categories in the tool to structure the content of the conversations. Supervisors tended to talk about the trainees' actions and their own frames rather than attempting to understand the trainees' perceptions. Supervisors and trainees welcomed the feedback opportunity and agreed that the conversations were useful and comprehensive.
The content of the feedback conversations reflected the contents of the tool and the feedback was considered useful and comprehensive. However, supervisors talked primarily about their own frames, so in order for the feedback to reach its full potential, supervisors may benefit from training techniques to stimulate a deeper reflection among trainees.
... Los estudios mostraron que, de hecho, los niveles de reflexión en los debriefings no son muy profundos en los escenarios, al menos para los participantes menos experimentados, y que la mayoría de las interacciones son relatos de lo que sucedió en el escenario con algunas descripciones de por qué este fue el caso. (Kihlgren, 2015) (Husebo, 2013). Las conexiones adicionales entre la situación y las acciones de los involucrados se discuten mucho menos. ...
El capítulo describe algunas estrategias para promover la reflexión en simulación y plantea algunas estrategias de diseño de escenarios y otras de debriefing para lograr este propósito.
... This emphasis can also be seen in studies that set out to measure the quality and character of student reflection during debriefings (e.g. Kihlgren et al., 2015). By coding different stages of reflection in a video-recorded debriefing session, for instance, Husebø et al. (2013) conclude that these activities 'provide students with the opportunity to reflect on their simulation experience ' (p. ...
The literature on simulation-based training highlights the importance of post-simulation debriefings as occasions for student self-reflection. Another central feature of these debriefings, which has not gained the same interest, is how debriefings are used by instructors to demonstrate professional modes of reflection-inaction: how they are used to show the deeply reasoned and skilled practices that characterize professional conduct. Based on video recordings of debriefing sessions in a navigation course for master mariners, this study discusses a case where an instructor demonstrates how navigational rules should be applied in line with good seamanship. With a starting point in the visual representation of the scenario, and by re-enacting the students' performance, the instructor formulates the problem that the students confronted in the scenario as well as potential solutions. In this way, the students' attempts to solve the task are explicated in terms of the more general lessons that the scenario was designed to teach. The study concludes by a) discussing the empirical case in relation to Schön's 'Educating the Reflective Practitioner' and b) outlining some implications for educational practice.
... Through reflection-in-action during high-fidelity simulation, new action occurs and the learners within the simulation are able to respond to their assessment findings correctly and intervene appropriately (Clapper and Leighton, 2019;Fraser et al., 2018;Geithner and Menzel, 2016). The ability to perform a new action also manifests in an increased ability to adapt to change and improvise when things are unexpected (Anderson et al., 2008;Kihlgren et al., 2014;Padden-Denmead et al., 2016). Student-identified outcomes of reflection-in-action during high-fidelity simulation include gaining skills, understanding or new knowledge, and increasing self-confidence (Clapper and Leighton, 2019;Hüsebo et al., 2015;Söderström et al., 2014). ...
Objectives
Our primary aim was to complete an in-depth analysis of the concept of “reflection-in-action” during high-fidelity simulation. We sought to identify what is currently known about the topic and establish a strong foundation for theory development regarding cultivating reflection-in-action during high-fidelity simulation.
Design
Walker and Avant's (2011) systematic approach to concept analysis was used as a framework to develop a comprehensive understanding of reflection-in-action during high-fidelity simulation.
Data sources
We conducted a review of literature on reflection-in-action (with open date parameters) in PubMed, Eric, PsychInfo, ABI/Business Premium Collection, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) electronic data bases using key terms “reflection-in-action” AND “simulation”. In addition, we hand-searched reference lists from key articles in the journals Simulation in Healthcare, Simulation and Gaming, and Advances in Simulation.
Results
Our search resulted in 22 articles, from 1998 to 2019, that met the inclusion criteria. Four defining attributes of the concept were identified: (1) reflection-in-action must occur during high-fidelity simulation and cannot be captured within post-simulation debriefing; (2) a critical learning juncture must occur and be identified by the learners; (3) a pause in student action must occur during the high-fidelity simulation; and (4) knowledge sharing must occur through out-loud discussion. Antecedents, consequences, and empirical referents of reflection-in-action were also identified.
Conclusions
The insights from this review may enhance the ability of nursing educators to effectively support reflection-in-action within high-fidelity simulation nursing education. This concept analysis also establishes a foundation for reflection-in-action strategy development, as well as suggestions for future research in high-fidelity simulation nursing education.
... 44 El debriefing se reconoce como el espacio para reflexionar luego de la simulación y para promover aprendizajes a largo plazo. El análisis conversacional de los debriefing de médicos jóvenes ha aportado alguna información sobre las interacciones que se produce en esas instancias, 45 reconociendo que muchas de las interacciones se quedan en la superficie y no logran promover efectivamente reflexiones profundas. ...
Simulation has been used within medical undergraduate curricula to promote the development of procedural skills, communication with patients, patients delivery, ethical reasoning and teamwork. The process of collecting, integrating and confirming information that constitute the basis of clinical reasoning necessary for medical decision making, is one of the essential competences training these professionals, and still presents difficulties to curricular planners. Although many recognize that their teaching is predominantly clinical, others think that the best way to teach clinical reasoning is not yet known. Simulation with standardized patients, computer-based virtual simulators, immersive simulation and high fidelity simulation, can be useful from the beginning of the curriculum, but they must be accompanied by feedback or debriefing. It is necessary to develop longitudinal studies, since clinical reasoning is a complex task whose development is established throughout the curricula and identify effective strategies to facilitate debriefing and promote clinical reasoning or the analysis of cognitive errors in decision making.
... 23 Another study which investigated novice doctors' reflection during debriefings concluded that the relatively inexperienced participants only reached lower levels of reflection. 24 They could however not note any differences in the instructor interventions across different levels of participant reflection. ...
Introduction
Analyses of simulation performance taking place during postsimulation debriefings have been described as iterating through phases of unawareness of problems, identifying problems, explaining the problems and suggesting alternative strategies or solutions to manage the problems. However, little is known about the mechanisms that contribute to shifting from one such phase to the subsequent one. The aim was to study which kinds of facilitator interactions contribute to advancing the participants’ analyses during video-assisted postsimulation debriefing.
Methods
Successful facilitator behaviours were analysed by performing an Interaction-Analytic case study, a method for video analysis with roots in ethnography. Video data were collected from simulation courses involving medical and midwifery students facilitated by highly experienced facilitators (6–18 years, two paediatricians and one midwife) and analysed using the Transana software. A total of 110 successful facilitator interventions were observed in four video-assisted debriefings and 94 of these were included in the analysis. As a starting point, the participants’ discussions were first analysed using the phases of a previously described framework, uPEA (unawareness (u), problem identification (P), explanation (E) and alternative strategies/solutions (A)). Facilitator interventions immediately preceding each shift from one phase to the next were thereafter scrutinised in detail.
Results
Fifteen recurring facilitator behaviours preceding successful shifts to higher uPEA levels were identified. While there was some overlap, most of the identified facilitator interventions were observed during specific phases of the debriefings. The most salient facilitator interventions preceding shifts to subsequent uPEA levels were respectively: use of video recordings to draw attention to problems (P), questions about opinions and rationales to encourage explanations (E) and dramatising hypothetical scenarios to encourage alternative strategies (A).
Conclusions
This study contributes to the understanding of how certain facilitator behaviours can contribute to the participants’ analyses of simulation performance during specific phases of video-assisted debriefing.
... 10 12 Many employees engage in 'protective strategies' 13 such as face-saving actions: withdrawal, reluctance to ask for help and disclose errors and obscuring critique. 10 12 14 This culture may suppress reflection in some debriefings, 15 limiting feedback effectiveness in healthcare team trainings. 16 Learning-oriented behaviours like speaking up, asking for help, admitting one is wrong or sharing assumptions, require participants to overcome feelings of defensiveness in discussing suboptimal performance. ...
Debriefings should promote reflection and help learners make sense of events. Threats to psychological safety can undermine reflective learning conversations and may inhibit transfer of key lessons from simulated cases to the general patient care context. Therefore, effective debriefings require high degrees of psychological safety—the perception that it is safe to take interpersonal risks and that one will not be embarrassed, rejected or otherwise punished for speaking their mind, not knowing or asking questions. The role of introductions, learning contracts and prebriefing in establishing psychological safety is well described in the literature. How to maintain psychological safety, while also being able to identify and restore psychological safety during debriefings, is less well understood. This review has several aims. First, we provide a detailed definition of psychological safety and justify its importance for debriefings. Second, we recommend specific strategies debriefers can use throughout the debriefing to build and maintain psychological safety. We base these recommendations on a literature review and on our own experiences as simulation educators. Third, we examine how debriefers might actively address perceived breaches to restore psychological safety. Re-establishing psychological safety after temporary threats or breaches can seem particularly daunting. To demystify this process, we invoke the metaphor of a ‘safe container’ for learning; a space where learners can feel secure enough to work at the edge of expertise without threat of humiliation. We conclude with a discussion of limitations and implications, particularly with respect to faculty development.
... 19 Other authors also emphasised that the quality of (self-led) debriefings is often low. 37 Such aspects are likely to increase in importance as the complexity of tasks increases. It could thus be that the quality of the briefings was sufficient to increase basic aspects of performance but not more complex ones. ...
Background
Teams that regularly step back from action and deliberately reflect on their performance and strategies show higher performance. Ad hoc emergency teams with changing team composition cannot develop such habits but may engage in short postaction reflection to discuss shortcomings of past performance and potential adaptations of their strategies for future similar tasks. This study aimed to test the effect of a short postaction self-led reflective team briefing on resuscitation performance in a simulator setting in terms of three performance parameters: hands-on time, coordination between chest compression and ventilation, and defibrillation.
Methods
We performed a randomised controlled trial including 56 ad hoc formed teams of three fourth-year medical students each. All groups performed a resuscitation task, followed by a self-guided reflective briefing, based on a general instruction (n=28 teams), or an unrelated discussion session (control condition; n=29), followed by a second resuscitation task in the same team composition.
Results
Adjusted for performance in the first task, teams in the reflection condition showed higher performance gain in the second resuscitation than teams in the control condition (6.21 percentage points (95% CI 1.31 to 11.10, p<0.001)) for basic hands-on performance; 15.0 percentage points (95% CI 2 to 28, p<0.001) for coordinative performance but non-significantly lower performance for defibrillation (−9%, 95% CI −27% to –9%, p=0.312).
Conclusion
Even very short self-led postaction reflective briefings enhance basic resuscitation performance in ad hoc groups but may not influence more complex aspects of the task. We recommend including short self-led team debriefings as part of simulator training.
... Nevertheless, teams can only learn and grow by identifying areas of improvement. Therefore, we recommend explicitly incorporating TR into SBTT because simulation provides an ideal environment to learn reflexive processes, which have room for improvement (Kihlgren et al. 2015). If teams embrace these processes and incorporate them into their everyday clinical practice, they acquire a valuable team skill that promotes self-development and continuously optimizes their performance. ...
Due to increasing complexity in healthcare, clinicians must often make decisions under uncertain conditions in which teams must be flexible and process emerging information “on the fly” in order to adapt to changing circumstances. A crucial strategy that helps teams to adapt, learn, and develop is team reflexivity (TR) – a team’s ability to collectively reflect on group objectives, strategies, processes, and outcomes of past and current performance and to adapt accordingly. We provide 12 evidence-based tips on incorporating TR into simulation-based team training (SBTT). The first three points elaborate on basic principles of TR, when TR can take place and why it matters. The following nine tips are then organized according to three phases in which teams are able to engage in TR: pre-action, in-action, and post-action. SBTT represents an ideal venue to train various TR behaviors that foster team learning and improve patient care.
... The debriefing in this study included theoretical knowledge and recommendations on care actions that had been overlooked or executed improperly. According to Kihlgren et al. (2015), this represents a lower level of reflection, more as an idea about doing a care action differently. To encourage learning, the debriefing needs to facilitate a deeper level of reflection (Husebø et al., 2015). ...
Simulation provides the opportunity to learn how to care for patients in complex situations, such as when patients are exposed to high-energy trauma such as motor vehicle accidents. The aim of the study was to describe nurses' perceptions of high-energy trauma care through simulation in prehospital emergency care. The study had a qualitative design. Interviews were conducted with 20 nurses after performing a simulated training series. Data were analyzed using a phenomenographic method. The result indicates that simulation establishes, corrects, and confirms knowledge and skills related to trauma care in prehosp ital emergency settings. Trauma knowledge is readily available in memory and can be quickly retrieved in a future trauma situation.
... The debriefing in this study included theoretical knowledge and recommendations on care actions that had been overlooked or executed improperly. According to Kihlgren et al. (2015), this represents a lower level of reflection, more as an idea about doing a care action differently. To encourage learning, the debriefing needs to facilitate a deeper level of reflection (Husebø et al., 2015). ...
Simulation provides the opportunity to learn how to care for patients in complex
situations, such as when patients are exposed to high-energy trauma such as motor vehicle accidents.
The aim of the study was to describe nurses’ perceptions of high-energy trauma care through simulation
in prehospital emergency care. The study had a qualitative design. Interviews were conducted
with 20 nurses after performing a simulated training series. Data were analyzed using a phenomenographic
method. The result indicates that simulation establishes, corrects, and confirms knowledge and
skills related to trauma care in prehosp ital emergency settings. Trauma knowledge is readily available
in memory and can be quickly retrieved in a future trauma situation.
... Debriefing refers to the conversation about the simulation experience that traditionally occurs post event (i.e. after the simulation ends) [1]. With debriefing conversations, facilitators strive to promote reflective processes essential for learning [2], but also to provide learners with information about their performance to help them improve [3]. In contrast to debriefing, which is widely viewed as the conversation, feedback refers to the specific information provided to the learner about their performance compared with a defined standard [4]. ...
Healthcare simulation continues to expand in a wide variety of venues, including undergraduate and postgraduate education as well as continuing professional development. Combined with scenarios designed with clear learning objectives in mind, debriefing remains a cornerstone of simulation-based education. A debriefing framework structures the conversation by outlining several phases to the debriefing process that serve specific functions. A commonly applied framework consists of three main phases: the reactions phase (where learner share their visceral emotions and initial reactions to the simulated experience); the analysis phase (where learners engage in reflective discussion and close performance gaps); and the summary phase (where key learning points are highlighted). Effective faculty development for debriefing relies on tools that yield valid and reliable information about debriefing quality. Two tools that focus on simulation educator debriefing performance have undergone psychometric testing: the Objective Structured Assessment of Debriefing (OSAD) and the Debriefing Assessment for Simulation in Healthcare (DASH).
... An improved understanding of NTS will help simulation course participants to perform better during the simulation and also promote the development of better care in the clinical setting. A shared understanding of NTS between facilitators and participants should facilitate the discussions and mutual understanding which in turn should lead to more effective and deeper reflection during debriefing [27,28]. ...
Acquiring the concepts of non-technical skills (NTS) beyond a superficial level is a challenge for healthcare professionals and simulation faculty. Current simulation-based approaches to teach NTS are challenged when learners have to master NTS concepts, clinically challenging situations, and simulation as a complex technique. The combination of all three aspects might overwhelm learners. To facilitate the deeper comprehension of NTS concepts, we describe an innovative video-based game, the Non-Technical Skills (NTS) Bingo. Participants get NTS Bingo cards that show five NTS elements each. While observing (non-medical) video clips, they try to find examples for the elements on their cards, typically observable behaviours that match a given element. After the video, participants “defend” their solution in a discussion with the game leader and other players. This discussion and the reflection aim to deepen the processing of the NTS concepts. We provide practical guidance for the conduct of NTS Bingo, including a selection of usable video clips and tips for the facilitated discussion after a clip. We use NTS in anaesthesia as example and provide guidance on how to adapt NTS Bingo to other disciplines. NTS Bingo is based on theoretical considerations on concept learning, which we describe to support the rationale for its conduct.
Electronic supplementary material
The online version of this article (doi:10.1186/s41077-016-0024-z) contains supplementary material, which is available to authorized users.
There continues to be a lack of detailed understanding of how debriefing works and how it enables learning. To further our understanding and simultaneously illuminate current knowledge, a metaethnographic qualitative synthesis was undertaken to address the research question: how are interactions in simulation debriefing related to participant learning? Ten databases were searched (up to November 2020) and 17 articles were selected for inclusion.Initial interpretive synthesis generated 37 new concepts that were further synthesized to produce a new theoretical framework. At the heart of the framework is a concept of reflective work, where participants and faculty recontextualize the simulation experience bidirectionally with clinical reality: a process that facilitates sensemaking. This occurs in a learning milieu where activities such as storytelling, performance evaluation, perspective sharing, agenda setting, and video use are undertaken. The outcome is conceptualization of new future roles, clinical competence, and professional language development-a process of transforming professional identity.
Background
In an earlier interview-based study the authors identified that learners experience one or more of eight explicit perceptual responses during the active phase of simulation-based training (SBT) comprising a sense: of belonging to instructor and group, of being under surveillance, of having autonomy and responsibility for patient management, of realism, of an understanding of the scenario in context, of conscious mental effort, of control of attention, and of engagement with task. These were adapted into a ten-item questionnaire: the Simulation Based Training Quality Assurance Tool (SBT-QA10) to allow monitoring of modifiable factors that may impact upon learners’ experiences. This study assessed the construct validity evidence of the interpretation of the results when using SBT-QAT10.
Materials and methods
Recently graduated doctors and nurses participating in a SBT course on the topic of the deteriorating patient completed the SBT-QAT10 immediately following their participation in the scenarios. The primary outcome measure was internal consistency of the questionnaire items and their correlation to learners’ satisfaction scores. A secondary outcome measure compared the impact of allocation to active versus observer role.
Results
A total of 349 questionnaires were returned by 96 course learners. The median of the total score for the ten perception items (TPS) was 39 (out of 50), with no significant difference between the scenarios. We identified fair and positive correlations between nine of the 10 items and the SBT-QA10-TPS, the exception being “mental effort”. Compared to observers, active learners reported significantly more positive perceptions related to belonging to the team and interaction with the instructor, their sense of acting independently, and being focused. The questionnaire items were poorly correlated with the two measures of global satisfaction.
Conclusion
Except for the item for mental effort, the QA10-TPS measures learners’ experiences during the active phase of simulation scenarios that are associated with a positive learning experience. The tool may have utility to learners, instructors, and course providers by informing subsequent debriefing and reflection upon practice for learners and faculty. The relationship between these perceptions and commonly used measures of satisfaction remains poorly understood raising questions about the value of the latter.
Background: In an earlier interview-based study the authors identified that learners experience one or more of eight explicit perceptual responses during the active phase of simulation-based training (SBT) comprising a sense: of belonging to instructor and group, of being under surveillance, of having autonomy and responsibility for patient management, of realism, of an understanding of the scenario in context, of conscious mental effort, of control of attention, and of engagement with task. These were adapted into a ten-item questionnaire: the Simulation Based Training Quality Assurance Tool (SBT-QA10) to allow monitoring of modifiable factors that may impact upon learners’ experiences. This study assessed the construct validity evidence of the interpretation of the results when using SBT-QAT10.
Materials and Methods: Recently graduated doctors and nurses participating in a SBT course on the topic of the deteriorating patient completed the SBT-QAT10 immediately following their participation in the scenarios. The primary outcome measure was internal consistency of the questionnaire items and their correlation to learners’ satisfaction scores. A secondary outcome measure compared the impact of allocation to active versus observer role.
Results:
A total of 349 questionnaires were returned by 96 course learners. The median of the total score for the ten perception items (TPS) was 39 (out of 50), with no significant difference between the four scenarios. We identified fair and positive correlations between nine of the 10 items and the SBT-QA10-TPS, the exception being “mental effort”. Compared to observers, active learners reported significantly more positive perceptions related to belonging to the team and interaction with the instructor, their sense of acting independently, and being focused. The questionnaire items were poorly correlated with the two measures of global satisfaction.
Conclusion: Except for the item for mental effort, the QA10-TPS measures learners’ experiences during the active phase of simulation scenarios that are associated with a positive learning experience. The tool may have utility to learners, instructors, and course providers by informing subsequent debriefing and reflection upon practice for learners and faculty. The relationship between these perceptions and commonly used measures of satisfaction remains poorly understood raising questions about the value of the latter.
Contexte : Le débriefing dans le secteur de la santé est souvent considéré comme un processus de réflexion centré sur l’apprenant nécessaire pour la construction des connaissances, où le formateur joue un rôle de facilitateur. Cependant, diverses études soulignent l’importance que le débriefing soit explicite pour les apprenants novices. Cet article examine l’efficacité de différents types de débriefing, simulation, pour des apprenants expérimentés qui travaillent dans des équipes d’urgence. Objectif : Cette étude vise à vérifier si le débriefing explicite est aussi efficace pour les professionnels expérimentés qu’il l’a été pour les apprenants novices. Méthodes : Cette étude prospective randomisée monocentrique a été réalisée dans le cadre d’un programme de simulation basé sur des interventions d’urgence lors d’un arrêt cardiaque. Les connaissances déclarées de chaque participant, leur auto-efficacité et l’efficacité de l’équipe ont été mesurées avant et après la formation par simulation. Résultats : Les résultats montrent un effet bénéfique sur les connaissances et l’auto-efficacité pour les deux types de débriefing. Les soins apportés aux patients ont aussi été optimisés pour les deux types de débriefing. Conclusion : Les deux types de débriefing post-simulation sont efficaces pour les équipes d’urgence expérimentées.
Background: Debriefing is an indispensable component of simulation-based medical education, and it has great potential for contributions to reflective learning. Little is known about the relevance of communication during debriefings. We developed a category framework to assess the communication content of debriefings, which we used to analyze possible relationships to participant learning outcomes.
Method: We deductively and inductively developed a category framework for qualitative content analysis of debriefings. We coded 20 debriefings using this framework, and correlated debriefing frequency with learning outcomes (i.e. engagement, satisfaction, individual and team learning success).
Results: The category framework comprised 9 main and 81 subcategories (48 debriefers, 27 participants, 6 simulated patients), which yielded good intercoder agreement. Debriefers and participants communicated equally using mostly advocacy, inquiry, illustration, and confirmation. Debriefer questions and participant inputs were positively related to learning outcomes. In contrast, guess-what-I-am-thinking, apologies, observations, use of materials, participant descriptions, simple repetition of statements, and evaluation by other participants were not positively associated with learning outcomes.
Conclusion: This study provides important new information about communication content during debriefings. The association between communication content and learning outcomes appears particularly relevant to further enhance efficacy of debriefings and simulation-based medical education.
Introduction: Singapore was one of the earliest countries affected by the COVID-19 outbreak, requiring our emergency department to respond urgently to this surge. A designated Fever Area (FA) with a resuscitation room was rapidly set up to manage patients at risk of COVID-19. Our paper describes measures put into this new area to optimise safety outcomes of these patients. Methods: Plan-Do-Study-Act (PDSA) cycles incorporating in-situ simulation in the FA resuscitation room were conducted. Using varied resuscitation scenarios and facilitated debriefing, we identified safety gaps and took immediate steps to rectify them in a collaborative manner involving various respective stakeholders. Results: Following reflective debriefing and studying of work processes, latent safety threats were identified resulting in successful improvements and modifications to protocols, equipment, staffing and processes in the FA resuscitation area. Conclusion: PDSA cycles involving in-situ simulation helped to identify safety threats and refine work processes in a newly set up FA facility. As a result, our healthcare team was more prepared to manage the complexities of COVID-19 patients in a high-risk environment.
The level of quality reflective practice remains low among student teachers majoring in Mathematics education. This paper aims to identify the levels of reflective practice possessed by Mathematics education student teachers in a teacher training program at higher learning institutions in Namibia. The professional status requires that teachers become reflective practitioners to develop their effectiveness- a skill they can acquire during their training. A reflection framework was used to identify levels of reflective practices among Mathematics student teachers. This study is qualitative and employed a narrative inquiry approach to assess the effectiveness of reflective practice as experienced by student teachers. A total of ten third-year undergraduate students majoring in Mathematics Education participated in the study by generating reflective journals. The results show that student teachers have insufficient reflective skills which are limited to the first two levels of the reflection framework: technical reflection and reflection-in-and-on-action. This could be due to little guidance offered on developing reflective skills and its use by student teachers. This study's findings will be used to improve the rationality, social and educational practices among the student teachers.
Background:
Medical practitioners' reflective skills are increasingly considered important and therefore included in the medical education curriculum. However, assessing students' reflective skills using rubrics does not appear to guarantee adequate inter-rater reliabilities. Recently, comparative judgment was introduced as a new method to evaluate performance assessments. This study investigates the merits and limitations of the comparative judgment method for assessing students' written self-reflections. More specifically, it examines the reliability in relation to the time spent assessing, the correlation between the scores obtained using the two methods (rubrics and comparative judgment), and, raters' perceptions of the comparative judgment method. Approach: Twenty-two self-reflections, that had previously been scored using a rubric, were assessed by a group of eight raters using comparative judgment. Two hundred comparisons were completed and a rank order was calculated. Raters' impressions were investigated using a focus group.
Findings:
Using comparative judgment, each self-reflection needed to be compared seven times with another self-reflection to reach a scale separation reliability of .55. The inter-rater reliability of rating (ICC, (1, k)) using rubrics was .56. The time investment required for these reliability levels in both methods was around 24 minutes. The Kendall's tau rank correlation indicated a strong correlation between the scores obtained via both methods. Raters reported that making comparisons made them evaluate the quality of self-reflections in a more nuanced way. Time investment was, however, considered heavy, especially for the first comparisons. Although raters appreciated that they did not have to assign a grade to each self-reflection, the fact that the method does not automatically lead to a grade or feedback was considered a downside.
Conclusions:
First evidence was provided for the comparative judgment method as an alternative to using rubrics for assessing students' written self-reflections. Before comparative judgment can be implemented for summative assessment, more research is needed on the time investment required to ensure no contradictory feedback is given back to students. Moreover, as the comparative judgment method requires an additional standard setting exercise to obtain grades, more research is warranted on the merits and limitations of this method when a pass/fail approach is used.
Introduction
Debriefing is a core element in simulation-based education but successful debriefing modalities remain unspecified. In educational sciences, teaching approaches that are structured, explicit and instructor directed have been shown to be systematically more effective than implicit, reflective approaches with minimal guidance, particularly for novice or intermediate learners. The aim of this study is to compare explicit, highly guided debriefing with implicit and low-guided debriefing in nurse education.
Method
This study is a single-centre randomised prospective study comparing the efficacy of explicit, implicit or mixed debriefing procedures. The experimental modalities focused on the description and the analysis phase of the debriefing. The primary outcome was knowledge. The secondary outcomes were self-efficacy and self-confidence.
Results
136 nursing students participated during 46 simulation sessions. Knowledge, self-efficacy and self-confidence increased in all conditions. Linear regression analysis showed that knowledge learning was higher in the debriefing conditions in which the analysis was carried out in an explicit manner. There was no debriefing type effect on self-efficacy and self-confidence increase.
Conclusion
For nursing students, using explicit, highly guided debriefing with direct teaching of content was shown to be more effective on learning than implicit, reflective debriefing with little guidance.
Team neurodynamics is the study of the changing rhythms and organizations of teams from the perspective of neurophysiology. As a discipline, team neurodynamics is located at the intersection of collaborative learning, psychometrics, complexity theory, and neurobiology with the resulting principles and applications both drawing from and contributing to these specialties. This article describes the tools for studying team neurodynamics and illustrates the potential and the challenges these methods and models have for better understanding healthcare team training and performance. The fundamental metric is neurodynamic organization, which is the tendency of teams and its members to enter into prolonged metastable relationships when they experience and resolve uncertainty. The patterns of these relationships are resolved by symbolic modeling of electroencephalographic (EEG) power levels of the team members, and the information in these patterns are calculated using information theory tools. The topics discussed in this chapter anticipate the time when dynamic biometric data can contribute to our understanding of how to rapidly determine a team’s functional status, and how to use this information to optimize outcomes and training. The rapid, dynamic, and task neutral measures make the lessons learned in healthcare applicable to other complex group and team environments, and provide a foundation for incorporating these models into machines to support the training and performance of teams.
The final chapter of the book reflects on the challenges and benefits of interprofessional research collaboration, sharing data, and the application of different theoretical lenses when focusing on different aspects of practices, located in different national and international contexts. The chapter also outlines some challenges for the development of future simulation pedagogy, based on the findings of the collated research, and discusses areas in need for further research and development.
Simulation ist ein rasch wachsendes Forschungsfeld und beinhaltet 2 Schwerpunkte: Simulation als Trainingsmethode und Simulation als Untersuchungsmethode. Die Forschung zur Simulation als Trainingsmethode ist v. a. anwendungsorientiert mit dem Ziel, Informationen darüber zu erlangen, wie Simulationstrainings gestaltet werden können, damit die Teilnehmenden möglichst viel und nachhaltig lernen. Die Forschung mit Simulation als Untersuchungsmethode beinhaltet v. a. Grundlagenforschung mit dem Ziel, via Simulation Prozesse und Zusammenhänge zu untersuchen, die sonst nicht oder weniger gut zu untersuchen wären. In diesem Kapitel geben wir einen kurzen Überblick über beide Forschungsgebiete, weisen auf interdisziplinäre Herausforderungen und aktuelle Forschungslücken hin und bieten dazu Handlungsempfehlungen an.
Debriefing, die Nachbesprechung eines Simulationsszenarios, ist ein sehr wichtiger Bestandteil des simulationsgestützten Lernens. Viele der Reflexionen und Einsichten, die sich im Zusammenhang mit der Simulation ergeben, werden hier bewusst und explizit gemacht. Debriefings haben verschiedene Phasen, in der der Debriefer mit den Teilnehmern daran arbeitet, die Lernziele der Simulation umzusetzen. Gerade in den letzten Jahren bekam diese Kursphase viel Aufmerksamkeit, und eine Reihe von Verfahren wurde entwickelt. Gemeinsam ist diesen Modellen in der Regel, dass die Gruppe sich einen Überblick darüber verschafft, was im Szenario konkret geschah, dann einzelne Aspekte genauer analysiert und schließlich beschreibt, welche Lerneinsichten und Änderungsintentionen sich aus der Diskussion ergeben haben. Viele Faktoren beeinflussen, wie ein Debriefing abläuft, z. B. die Gruppendynamik, kulturelle Unterschiede und Gemeinsamkeiten innerhalb der Gruppe oder die Erfahrung der Debriefer und Teilnehmer. Zunehmend werden Debriefingmethoden, die in der Simulation entwickelt wurden, auch in klinischen Zusammenhängen eingesetzt.
Debriefings are crucial for learning during simulation-based training (SBT). Although the quality of debriefings is very important for SBT, few studies have examined actual debriefing conversations. Investigating debriefing conversations is important for identifying typical debriefer–learner interaction patterns, obtaining insights into associations between debriefers’ communication and learners’ reflection and comparing different debriefing approaches. We aim at contributing to the science of debriefings by developing DE-CODE, a valid and reliable coding scheme for assessing debriefers’ and learners’ communication in debriefings. It is applicable for both direct, on-site observations and video-based coding.
Methods
The coding scheme was developed both deductively and inductively from literature on team learning and debriefing and observing debriefings during SBT, respectively. Inter-rater reliability was calculated using Cohen’s kappa. DE-CODE was tested for both live and video-based coding.
Results
DE-CODE consists of 32 codes for debriefers’ communication and 15 codes for learners’ communication. For live coding, coders achieved good inter-rater reliabilities with the exception of four codes for debriefers’ communication and two codes for learners’ communication. For video-based coding, coders achieved substantial inter-rater reliabilities with the exception of five codes for debriefers’ communication and three codes for learners’ communication.
Conclusion
DE-CODE is designed as micro-level measurement tool for coding debriefing conversations applicable to any debriefing of SBT in any field (except for the code medical input). It is reliable for direct, on-site observations as well as for video-based coding. DE-CODE is intended to allow for obtaining insights into what works and what does not work during debriefings and contribute to the science of debriefing.
Professionalism is an essential element of healthcare professional curriculum. However, teaching professionalism is complex and requires engaging and effective strategies. Virtual patients, in the form of computer-generated simulated clinical scenarios, can be used as a strategy to teach professionalism. The use of virtual patients provides an interactive and accessible learning tool along with opportunities for repetitive practice. This paper proposes twelve tips for utilizing virtual patients to teach healthcare professionalism. These tips are based on an extensive review of the relevant literature and the author's experience. The application of these tips may facilitate teaching professionalism using virtual patients and improve learning and retention of information.
In this article, we review the debriefing literature and point to the dilemma that although debriefings especially intend to enhance team (rather than individual) learning, it is particularly this team setting that poses risks for debriefing effectiveness (e.g., preference-consistent information sharing, lack of psychological safety inhibiting structured information sharing, ineffective debriefing models). These risks can be managed with a mindful approach with respect to content (e.g., specific learning objectives), structure (e.g., reactions phase, analysis phase, summary phase), attitude (e.g., honesty, curiosity, holding the trainee in positive regard) and setting (e.g., briefings to provide orientation and establish psychological safety). We point to the potential of integrating systemic methods such as circular questions into debriefings, discuss the empirical evidence for debriefing effectiveness and highlight the importance of faculty development.
Copyright © 2015 Elsevier Ltd. All rights reserved.
Objective: This paper explores the nursing literature to identify the educative process and essential features of debriefing. Setting: Nursing education settings: undergraduate, postgraduate and professional development in nursing and midwifery. Data sources: Studies of debriefing in nurse education were located in peer reviewed journals between 1990 and May 2010. Searches were made using keywords in six healthcare and one education database. Eleven nursing studies reporting education of individuals and six studies of teams were selected for inclusion; only one study provided learning outcome data. Hence, the literature was synthesised in a narrative form to include related studies. Primary argument: Formative feedback is important in experiential learning and is often applied in nursing in the form of facilitated structured debriefing. Debriefing is most commonly reported in relation to clinical skills development and as part of individual and team-based simulation training. Educational outcomes are dependant upon the skills of the facilitator in offering feedback in accordance with best practice. Although a key component of higher level education, there is a lack of published evidence with regard to the effectiveness of debriefing techniques in nurse education. A framework for debriefing practice is presented. Conclusion: Structured facilitated debriefing is an important strategy to engage students in learning and is essential in simulation training. Further research is warranted to fully understand the impact of the method in nurse education.
BACKGROUND:
Effective team performance is essential in the delivery of high-quality health-care. Leadership skills therefore are an important part of physicians' everyday clinical life. To date, the development of leadership skills are underrepresented in medical curricula. Appropriate training methods for equipping doctors with these leadership skills are highly desirable.
OBJECTIVE:
The review aims to summarize the findings in the current literature regarding training in leadership skills in medicine and tries to integrate the findings to guide future research and training development.
METHOD:
The PubMED, ERIC, and PsycArticles, PsycINFO, PSYNDEX and Academic search complete of EBSCOhost were searched for training of leadership skills in medicine in German and English. Relevant articles were identified and findings were integrated and consolidated regarding the leadership principles, target group of training and number of participants, temporal resources of the training, training content and methods, the evaluation design and trainings effects.
RESULTS:
Eight studies met all inclusion criteria and no exclusion criteria. The range of training programs is very broad and leadership skill components are diverse. Training designs implied theoretical reflections of leadership phenomena as well as discussions of case studies from practice. The duration of training ranged from several hours to years. Reactions of participants to trainings were positive, yet no behavioral changes through training were examined.
CONCLUSIONS:
More research is needed to understand the factors critical to success in the development of leadership skills in medical education and to adapt goal-oriented training methods. Requirements analysis might help to gain knowledge about the nature of leadership skills in medicine. The authors propose a stronger focus on behavioral training methods like simulation-based training for leadership skills in medical education.
This paper reports on a study undertaken by two university‐based teacher educators into an aspect of professional practice. The feasibility and desirability of assessing reflection demonstrated by student teachers studying early childhood literacy was investigated. While reaffirming the importance of developing reflective practitioners, the study highlighted the difficulties of equitably or meaningfully assessing reflection. Use of alternative methodologies was called for in future research into reflection
Describing what simulation centre leaders see as the ideal debriefing for different simulator courses (medical vs. crisis resource management (CRM)-oriented). Describing the practice of debriefing based on interactions between instructors and training participants.
Study 1 - Electronic questionnaire on the relevance of different roles of the medical teacher for debriefing (facilitator, role model, information provider, assessor, planner, resource developer) sent to simulation centre leaders. Study 2 - Observation study using a paper-and-pencil tool to code interactions during debriefings in simulation courses for CRM for content (medical vs. CRM-oriented) and type (question vs. utterance).
Study 1 - The different roles were seen as equally important for both course types with the exception of 'information provider' which was seen as more relevant for medical courses. Study 2 - There were different interaction patterns during debriefings: line - involving mostly the instructor and one course participant, triangle - instructor and two participants, fan - instructor and all participants in a dyadic form and net - all participants and the instructor with cross references.
What simulation centre heads think is important for the role mix of simulation instructors is (at least partly) not reflected in debriefing practice.
The importance of reflection and reflective practice are frequently noted in the literature; indeed, reflective capacity is regarded by many as an essential characteristic for professional competence. Educators assert that the emergence of reflective practice is part of a change that acknowledges the need for students to act and to think professionally as an integral part of learning throughout their courses of study, integrating theory and practice from the outset. Activities to promote reflection are now being incorporated into undergraduate, postgraduate and continuing medical education, and across a variety of health professions. The evidence to support and inform these curricular interventions and innovations remains largely theoretical. Further, the literature is dispersed across several fields, and it is unclear which approaches may have efficacy or impact. We, therefore, designed a literature review to evaluate the existing evidence about reflection and reflective practice and their utility in health professional education. Our aim was to understand the key variables influencing this educational process, identify gaps in the evidence, and to explore any implications for educational practice and research.
Reflection on personal experience is described as a means to learn from experience, enable self-development and improve professional practice amongst other things. Recently there has been a move in HCI to explore new ways technology may support us in doing this. However, within this community there is little use made of existing literature to evaluate how well such tools support this reflection. In this paper we present a case study of the development of a 'levels of reflection' framework for the purposes of evaluating a wearable digital camera (SenseCam) to support teachers' and tutors' reflective practice. The framework enabled us to rate and compare reflection achieved by participants in different situations, and to explore the relationship between the ways images were used by participants and the level of reflection this led to, with implications for designing future SenseCam use to better support teachers' and tutors' reflection on experience. Beyond our particular case study, we suggest that the framework and associated methodological approach for rating reflection is of value to those within the HCI community interested in designing for reflection on experience. Rating reflection in this way can enable new tools or techniques for supporting reflection to be explored over time, across similar situations or with adaptations, and to build understandings of how reflection is being most effectively supported - ultimately inspiring the design of future technologies by building up an understanding of the most effective ways of supporting reflection on experience.
OBJECTIVE: To investigate the impact of instructor feedback versus no instructor feedback when training a complex operational task on a laparoscopic virtual reality simulator.
BACKGROUND: Simulators are now widely accepted as a training tool, but there is insufficient knowledge about how much feedback is necessary, which is useful for sustainable implementation.
METHODS: A randomized trial complying with CONSORT Statement. All participants had to reach a predefined proficiency level for a complex operational task on a virtual reality simulator. The intervention group received standardized instructor feedback a maximum of 3 times. The control group did not receive instructor feedback. Participants were senior medical students without prior laparoscopic experience (n = 99). Outcome measures were time, repetitions, and performance score to reach a predefined proficiency level. Furthermore, influence of sex and perception of own surgical skills were examined.
RESULTS: Time (in minutes) and repetitions were reduced in the intervention group (162 vs 342 minutes; P < 0.005) and (29 vs 65 repetitions; P < 0.005). The control group achieved a higher performance score than the intervention group (57% vs 49%; P = 0.004). Men used less time (in minutes) than women (P = 0.037), but no sex difference was observed for repetitions (P = 0.20). Participants in the intervention group had higher self-perception regarding surgical skills after the trial (P = 0.011).
CONCLUSIONS: Instructor feedback increases the efficiency when training a complex operational task on a virtual reality simulator; time and repetitions used to achieve a predefined proficiency level were significantly reduced in the group that received instructor feedback compared with the control group. Trial registration number: NCT01497782.
PMID: 23295321 [PubMed - indexed for MEDLINE]
Background: Simulation is a time- and cost-intensive teaching modality that consists of both hands-on experience with a lifelike manikin and a debriefing session. While many educators believe that both simulation components are important for learning, the impact of the individual components is unknown. Objectives: The purpose of this study was to determine where in a simulation experience greater knowledge gains occurred. Methods: With a 2-group, repeated measures, experimental design, this study examined the impact of simulation components (hands-on alone and hands-on plus debriefing) on heart failure (HF) clinical knowledge in 162 prelicensure nursing students (age: M = 25.7 years, SD = 6.6 years; 85.5% women) from 3 nursing schools who were at the same point in their curriculum. Parallel HF knowledge tests were given at baseline (Pretest) and after the hands-on (Posttest 1) and debriefing (Posttest 2) stages of the HF simulation. Results: HF knowledge scores decreased from the pretest to the first posttest (after the hands-on component of the simulation; M = -5.63, SD = 3.89; p < .001), whereas they dramatically improved after debriefing (M = +6.75, SD = 4.32; p = < .001). Conclusion: Gains in HF knowledge were achieved only after debriefing. This study suggests that the debriefing experience should be emphasized in a standardized simulation learning experience. Further investigation is needed to evaluate the impact of debriefing and intensive teaching without the hands-on simulation component. © 2011 International Nursing Association for Clinical Simulation and Learning.
Preparing to facilitate the debriefing part of a simulation game requires as much care and attention as preparing to lead the introductory and play parts. This article provides a sort of mini-manual; explaining the nature of facilitating and then guiding the reader through the three phases of description, analysis/analogy, and application. It suggests questions a facilitator might use during each of these phases.
Existing research into learning about patient safety focuses on identifying how educational interventions improve educational outcomes but few studies offer evidence that inform educators about the mechanisms involved in learning about patient safety. The current evidence based in undergraduates is also limited to outcomes that relate to knowledge and skills. A realist approach involving three cycles of data collection in a single cohort of students over 5 years used different outcomes in Kirkpatrick's framework to identify the mechanisms that influence students learning about patient safety. Data source 1. Focus groups identified an overarching theoretical model of the mechanisms that influence patient safety learning for medical students. Data source 2 Identified if the mechanisms from data source 1 could be demonstrated at the outcome level of knowledge and attitudes. Data source 3 Established associations between mechanisms and outcomes at skills and behavioural level, in a standardised simulated ward setting. Data source 1: The interpretation of data from seven focus groups involving sixty students identified reflection at two levels of Mezirow's descriptions; reflection and critical reflection as mechanisms that influence learning about error. Data source 2: Sixty-one students participated. The associations found, reflection and knowledge of actions to take for patient safety, r = 0.44 (P = 0.00) and critical reflection and intentions regarding patient safety, r = 0.40 (P = 0.00) Data source 3: Forty-eight students participated. The correlation identified associations between critical reflection and planned changes following feedback was, r = 0.48 (P = 0.00) and reflection and knowledge based errors r = -0.30 (P = 0.03). A realist approach identified two different levels of reflection were associated with different patient safety outcomes for this cohort of students. Critical reflection was associated with attitudes and reflection was associated with knowledge of actions and error behaviours. These findings give educators greater depth of information about the role of reflection in patient safety.
Debriefing is a lynchpin in the process of learning. As a post-experience analytic process, debriefing is a discussion and analysis of an experience, evaluating and integrating lessons learned into one's cognition and consciousness. Debriefing provides opportunities for exploring and making sense of what happened during an event or experience, discussing what went well and identifying what could be done to change, improve and do better next time. This manuscript serves as an introduction to debriefing, covering a range of topics that include a brief review of its origin, the structure and process of debriefing-specifically in the context of simulation-based medical education, and factors that facilitate effective, successful debriefing. An approach to debriefing immediately after real clinical events will be presented, as well as an evidence-based approach to evaluating debriefing skills of healthcare simulation instructors.
Summary statement:
Debriefing plays a critical role in facilitated reflection of simulation after the experiential component of simulation-based learning. The concept of framing and reflective learning in a debriefing session has emanated primarily from Western cultures. However, non-Western cultures have significant characteristics that manifest themselves in teaching and learning practices substantially different from Western cultures. We need to consider how to balance standardization in debriefing with a culture-sensitive interpretation of simulation-based learning so that learners receive the maximum benefit from debriefing sessions. Our goal was to raise awareness of cultural differences and stimulate work to make progress in this regard.
Debriefs (or "after-action reviews") are increasingly used in training and work environments as a means of learning from experience. We sought to unify a fragmented literature and assess the efficacy of debriefs with a quantitative review.
Used by the U.S. Army to improve performance for decades, and increasingly in medical, aviation, and other communities, debriefs systematize reflection, discussion, and goal setting to promote experiential learning. Unfortunately, research and theory on debriefing has been spread across diverse disciplines, so it has been difficult to definitively ascertain debriefing effectiveness and how to enhance its effectiveness.
We conducted an extensive quantitative meta-analysis across a diverse body of published and unpublished research on team- and individual-level debriefs.
Findings from 46 samples (N = 2,136) indicate that on average, debriefs improve effectiveness over a control group by approximately 25% (d = .67). Average effect sizes were similar for teams and individuals, across simulated and real settings, for within- or between-group control designs, and for medical and nonmedical samples. Meta-analytic methods revealed a bolstering effect of alignment and the potential impact of facilitation and structure.
Organizations can improve individual and team performance by approximately 20% to 25% by using properly conducted debriefs.
Debriefs are a relatively inexpensive and quick intervention for enhancing performance. Our results lend support for continued and expanded use of debriefing in training and in situ. To gain maximum results, it is important to ensure alignment between participants, focus and intent, and level of measurement.
Introduction:
Simulation-based education is a learner-active method that may enhance teamwork skills such as leadership and communication. The importance of postsimulation debriefing to promote reflection is well accepted, but many questions concerning whether and how faculty promote reflection remain largely unanswered in the research literature. The aim of this study was therefore to explore the depth of reflection expressed in questions by facilitators and responses from nursing students during postsimulation debriefings.
Methods:
Eighty-one nursing students and 4 facilitators participated. The data were collected in February and March 2008, the analysis being conducted on 24 video-recorded debriefings from simulated resuscitation teamwork involving nursing students only. Using Gibbs' reflective cycle, we graded the facilitators' questions and nursing students' responses into stages of reflection and then correlated these.
Results:
Facilitators asked most evaluative and fewest emotional questions, whereas nursing students answered most evaluative and analytic responses and fewest emotional responses. The greatest difference between facilitators and nursing students was in the analytic stage. Only 23 (20%) of 117 questions asked by the facilitators were analytic, whereas 45 (35%) of 130 students' responses were rated as analytic. Nevertheless, the facilitators' descriptive questions also elicited student responses in other stages such as evaluative and analytic responses.
Conclusion:
We found that postsimulation debriefings provide students with the opportunity to reflect on their simulation experience. Still, if the debriefing is going to pave the way for student reflection, it is necessary to work further on structuring the debriefing to facilitate deeper reflection. Furthermore, it is important that facilitators consider what kind of questions they ask to promote reflection. We think future research on debriefing should focus on developing an analytical framework for grading reflective questions. Such research will inform and support facilitators in devising strategies for the promotion of learning through reflection in postsimulation debriefings.
Reflection is claimed as a goal in many teacher preparation programs, but its definition and how it might be fostered in student teachers are problematic issues. In this article, a report is provided of a review of literature on reflection, in particular focusing on strategies which assist its development in preservice programs. Next there is outlined a research project where types of reflection have been defined and applied to an analysis of student writing. Finally, the authors propose a framework for types of reflection as a basis for further research development in teacher education.
As the standards movement progresses, efforts to encourage reflection by student teachers are often undermined. In this piece, we analyze exemplars of student teacher reflection coming from two very different approaches to outcomes-based teacher preparation. We use these exemplars to develop a rubric that illuminates the dimensions and qualities of reflection. This rubric helps clarify how meaningful reflection and an emphasis on learning are not incompatible if the focus is placed on the process of learning, rather than on outcomes alone. Finally, we contend that engagement in the process of reflection and reflection on the moral enterprise of teaching can be considered as important outcomes in their own right.
The central focus of the research reported here was to evaluate the usefulness of peer interaction on the development of professional knowledge of prospective secondary mathematics teachers. Tracing the fate of two students involved in a teamed field-based practicum experience over the course of 11 weeks, the findings of the research indicate that the use of peer collaboration and collaborative reflection has the potential to facilitate teacher development. Peers helped problematize learning issues, teaching actions, and mathematics for one another. Their level of reflection increased in the process.
This study reviews the criteria for assessing reflective thinking, and investigates how the process of reflective thinking develops in preservice teachers. Reflections of preservice teachers are assessed from two perspectives: content and depth. The findings include variations in the content, and that the pace at which reflective thinking deepens depends on personal background, field experience contexts, and the mode of communication. The study includes insights into how to measure the quality of reflective thinking and how to enhance reflective thinking and cultivate reflective practitioners, including the kinds of experiences that could be incorporated in a teacher education program.
Debriefing is a process involving the active participation of learners, guided by a facilitator or instructor whose primary goal is to identify and close gaps in knowledge and skills. A review of existing research and a process for identifying future opportunities was undertaken.
A selective critical review of the literature on debriefing in simulation-based education was done. An iterative process of analysis, gathering input from audience participants, and consensus-based synthesis was conducted.
Research is sparse and limited in presentation for all important topic areas where debriefing is a primary variable. The importance of a format for reporting data on debriefing in a research context was realized and a "who, when, where, what, why" approach was proposed. Also, a graphical representation of the characteristics of debriefing studies was developed (Sim-PICO) to help guide simulation researchers in appropriate experimental design and reporting.
A few areas of debriefing practice where obvious gaps that deserve study were identified, such as comparing debriefing techniques, comparing trained versus untrained debriefers, and comparing the effect of different debriefing venues and times. A model for publication of research data was developed and presented which should help researchers clarify methodology in future work.
Incl. bibl., index. It is argued that professional education should be centered on enhancing the professional person's ability for "reflection-in-action," which is learning by doing and developing the ability for continued learned throughout the professional's career. Examples are drawn from an architectural design studio and the arts to demonstrate how reflection-in-action can be fostered in students and therefore in professionals in all areas. The approach involves active coaching by a master teacher, including giving students practice facing real problems, testing solutions, making mistakes, seeking help, and refining approaches. Extensive dialogues between teachers and students illustrate how reflection-in-action works, what encourages it, and behavior or attitudes that can prevent the development of reflectiveness. [ERIC]
The aim of this paper is to critically review what is felt to be important about the role of debriefing in the field of simulation-based learning, how it has come about and developed over time, and the different styles or approaches that are used and how effective the process is. A recent systematic review of high fidelity simulation literature identified feedback (including debriefing) as the most important feature of simulation-based medical education. 1 Despite this, there are surprisingly few papers in the peer-reviewed literature to illustrate how to debrief, how to teach or learn to debrief, what methods of debriefing exist and how effective they are at achieving learning objectives and goals. This review is by no means a systematic review of all the literature available on debriefing, and contains information from both peer and nonpeer reviewed sources such as meeting abstracts and presentations from within the medical field and other disciplines versed in the practice of debriefing such as military, psychology, and business. It also contains many examples of what expert facilitators have learned over years of practice in the area. We feel this would be of interest to novices in the field as an introduction to debriefing, and to experts to illustrate the gaps that currently exist, which might be addressed in further research within the medical simulation community and in collaborative ventures between other disciplines experienced in the art of debriefing.