the role of debriefing and guided reflection in simulation sharon decker, rn, ph.d., acns-bs, ccrn,...
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The Role of Debriefing and Guided Reflection in Simulation
The Role of Debriefing and Guided Reflection in Simulation
Sharon Decker, RN, Ph.D., ACNS-BS, CCRN, ANEFSharon Decker, RN, Ph.D., ACNS-BS, CCRN, ANEF
ObjectivesObjectives
• Compare the strategies and models of debriefing and guided reflection.
• Explore the integration of debriefing and guided reflection during simulation.
Introduction: Changes in SocietyIntroduction: Changes in Society
• Experiencing more chronic co-morbidities
• Under 10 of age experiencing co-morbidities
• Living longer with increased chronic health needs
• Expect more input in health care decisions
• A broader view of medicine and health
How have these changes impacted-
how we deliver education?
competencies required for our discipline?
Health Educators’: Challenge #1Health Educators’: Challenge #1
IntroductionIntroduction
Challenges for the Health Educator
“requires complex, sophisticated judgments and psychomotor skills…” (p.128)
IOM, Crossing the Quality Chasm (2001)
Federal CommittionsFederal Committions
Institute of Medicine (2004)
• recommended teaching environments
– Require demonstration of competencies in patient-care delivery, evidence-based practice, quality improvement, and informatics
New nursing graduates have difficulty transferring knowledge and skills to the practice setting
Clarke & Aiken, 2003
Del Bueno, 2005
Health Educators’: Challenge #2Health Educators’: Challenge #2
And …
“New graduates….not prepared for the new quality improvement environment will require additional costly orientation and training.”
Finkelman, A & Kenner, C., 2007
Have we changed the methods used in teaching and assessing clinical competence to meet the changing environment?
Support for simulation by regulation agencies:
Support for simulation by regulation agencies:
For example:
National Council of State Boards of Nursing(2005)
Prelicensure nursing educational programs might include innovative teaching strategies (simulation) that complement
clinical experiences
Support for simulationSupport for simulation
Nursing faculty to “be open to a variety of clinical teaching models” including
virtual reality and
simulated clinical experience
AACN, 2003, p.13
Support for simulation Support for simulation
“New information and technologies
may require new skills. And new
technologies, such as simulation, may
enhance skills…” (p. 129)IOM, Crossing the Quality Chasm (2001)
National Council of State Boards of NursingNational Council of State Boards of Nursing
Simulation defined:
An educational process where learning experiences are simulated to imitate the working environment and require the learner to demonstrate the procedural techniques, decision-making, and critical thinking needed to provide safe and competency patient care.
Regulation agencies: Regulation agencies:
For example:
United States Medical Licensure Examination
Assesses clinical skills through simulated patient
interactions (Standardized patients)
Objective Structured Clinical Examinations (OSCE’s) allows measurement of skills in communication, professionalism, and physical assessment
Regulation agencies: Regulation agencies:
National Board for Respiratory Care
Includes a Clinical Simulation Examination which consists of 10 separate patient management problems
The National Registry of Emergency Medical Technicians
Investigating the use of high-fidelity simulation to assess psychomotor and decision making skills
Simulation as an Educational StrategySimulation as an Educational Strategy
Unique teaching tool that requires the educator to
● develop competencies with a new set of skills
● and be a risk taker.
Could simulation be one mechanism for
safe practice based learning?
Professional Charge for the FutureProfessional Charge for the Future
Therefore, if we must reinvent clinical teaching in practice based learning environments
Promoting Reflective ThinkingPromoting Reflective Thinking
Simulation =
Patient Care Experience
+
Debriefing and/or Guided Reflection
Experience alone does not guarantee learning Need the integration of reflection
(Boud, Keogh, & Walker, 1985)
Adult Learning PrinciplesAdult Learning Principles
Diverse Learning Styles
Visual (realism, fidelity of the environment)
Auditory (verbal responses)
Tactile (hear and lung sounds)
Kinesthetic (handling equipment)
Adult Learning PrinciplesAdult Learning Principles
Constructivism
Learning = process of constructing meaning
Educator functions as a collaborative facilitator
Includes experiential learning
Active engagement
Reflective thought
Reflection: DefinedReflection: Defined
The process that allows practitioners to uncover and expose thoughts, feelings and behaviors
A form of self-assessment/analysis that forces practitioners to face incongruity and uncomfortable facts
Philosophic FrameworkPhilosophic Framework
Dewey (1910, 1916)• Learning is dependent upon integration of experience with
reflection and of theory with practice
SchÖn (1987)• Learning promoted through the use of a “reflective practicum” –
learning environment realistic in which faculty act as coach
Philosophic FrameworkPhilosophic Framework
Kolb (1984)• Learning enhanced through a synergistic transaction between
learner and the environment
Bandura (1977)• Learning enhanced – self-confidence promoted with active learning
ReflectionReflection
SchÖn
Reflection-on-action– After the event
– Think back – gain understanding
Reflection-in-action– During
– Prompted by unexpected event
Knowing-in-action (Thoughtful Thinking)– Unconscious, initiative knowing
Stages of Reflective ThinkingStages of Reflective Thinking
Non reflectors Don’t identify relationships
Reflectors Identified relationships between new and past knowledge
Critical reflectors Identified relationships and demonstrated self-analysis
Mezirow, J. (1981)
Wong, Kember, Chung, & Yan (1995)
Reflective ThinkingReflective Thinking
Enhances learning from experience
Helps expand clinical knowledge
Promotes reflective practice
Improves clinical judgmentGlaze, J. E. (2001)
Paget, T. (2001)
Murphy, J. I. (2004)
Reflective ThinkingReflective Thinking
Patient care varies with the nurse’s reflective abilities
minimal reflective abilities = illness oriented patient care;
reflective skills = care based on the individualized needs of the client.
Conway (1998)
But, learning from reflection is not automaticBut, learning from reflection is not automatic
demands active involvement in a clinical experience (Teekman, 2000) and
guidance throughout the reflective process (Johns, 1996; Tanner, 1999).
Barriers & Outcomesof Reflective ThinkingBarriers & Outcomesof Reflective Thinking
Barriers
Previous learning Fixations Socialization (as a nurse) Organizational culture
Outcomes
Heightened self-confidence Empathy Understanding Better patient care
Environment and Tools Environment and Tools
Environment Safe – non-threatening, trustful Circle Confidential Time equal to or longer then the scenario
Setting the Ground RulesSetting the Ground Rules
Confidential
Review objectives and expectations
Professional courtesy No interruptions Respect
Supportive not judgmental Don’t talk about anyone not present Positive before negative
Listen
Audio-Visual IntegrationAudio-Visual Integration
• Be proficient with the equipment
• Do not show a segment unless it is to be discussed
• Show only 3 to 4 critical segments
• Index critical segments Introduce each segment
• “This segment occurred … discuss what you were thinking as you…”
Show the segment Pause – all the learner to self-critique
DiscussionDiscussion
Do you include audio-visual segment during each simulation?
When would they be appropriate?
Thing to think about:
Confidentiality forms
Archiving of materials
Faculty Role and ResponsibilitiesFaculty Role and Responsibilities
Dual role – facilitator and instructor
Facilitator
guide learner
Instructor
enhance understanding of “deficiencies”
Self-discovery
Faculty Role and ResponsibilitiesFaculty Role and Responsibilities
Set expectations (outline the process)
Guide the session
Facilitate according to level of engagement
Include “quiet” learners
Integrate instructional points
Reinforce
Faculty Role and ResponsibilitiesFaculty Role and Responsibilities
Give your analysis last
Keep the discussion “learner centered”
Be an active listener
Use silence and pauses
Use questioning – if appropriate to
encourage discussions
identify issues
explore other options
“Was there anything that occurred during the situation that made you uncomfortable?”
“What could you have done…?”
DebriefingDebriefing
A process in which after an experience the learner is lead through a purposeful discussion related to the experience
Lederman, 1992; Fanning & Gaba, 2007
Debriefing: PurposeDebriefing: Purpose
Correct errors
Identify different ways of handling event next time
Encourage self-assessment
Promote reflective thinking
Debriefing - WhenDebriefing - When
During – (Frozen) Emphasize teaching Defuse a deteriorating situation Redirect Limit embarrassment
After
Facilitation Techniques with DebriefingFacilitation Techniques with Debriefing
High-Level Facilitation –
guidance
Intermediate-Level Facilitation –
elicit continued or deeper discussion and analysis
Low-Level Facilitation –
refrain from interrupting and review objective
Debriefing ModelsDebriefing Models
Questioning
What did you experience?
How did you perform overall?
What have you learned?
How would you change your performance?
How can you apply learning to the future?
Debriefing ModelsDebriefing Models
Plus - Delta
Plus + Delta –
Behaviors to improve onInclude both what and how
Examples of good behaviors
Debriefing ModelsDebriefing Models
Advocacy – Inquiry “I noticed ….”
“I’m concerned…”
“I was wondering…”
Guided ReflectionGuided Reflection
The process that allows practitioners to uncover and expose thoughts, feelings and behaviors
An active process of self-monitoring initiated by a state of doubt or puzzlement occurring during or after an experience
Guided Reflection: PurposeGuided Reflection: Purpose
Promotes insightfulness
Leads to discovery of new knowledge
New knowledge – to be applied in future situations
Guided Reflection: faculty (facilitator’s) role Guided Reflection: faculty (facilitator’s) role
Facilitator
Learners who make their own discoveries – even if disappointing are more likely to acknowledge and own these discoveries then if these insights are pointed out to them.
– Dewey, 1938
DescriptionWhat happened?
Conclusionwhat else could you
have done?
Action PlanIf it arose
would you do?
FeelingsWhat were your
thinking & feeling?
EvaluationWhat was good &
bad about the experience?
AnalysisWhat sense can
you make ofthe situation?
Gibbs (1988)Reflective Cycle
Experience
WHAT?Describe the event
SO WHAT?Analysis the event
Discover what learning emerges from the
reflection
New learning
NOW WHAT?Proposed action
Purposeful reflection
Driscoll, 2000The WHAT Model Of Reflection
Johns, 1995, 1996(Based on Carper’s Ways of Knowing)Johns, 1995, 1996(Based on Carper’s Ways of Knowing)
Aesthetics “learning and knowing self” grasping, interpreting, envisioning and responding”
Describe what influenced your actions during the scenario.
Personal “understanding personal dynamics and the ability to cope with the situation”
Discuss your satisfaction with your
actions during this scenario.
Johns, Johns,
Ethics “knowing what is right and wrong and being committed to take action on this basis”
Describe how your personal values and beliefs influenced your actions during this experience.
Empirics “identifying and acknowledging lack of knowledge”
Describe the knowledge and skills you have that influenced your decision making during this experience.
Johns, Johns,
Reflexivity “resolve the contradictions between what the practitioner’s aim to achieve and actual practice, with the intent to achieve more desirable and effective practice”
Describe situations you have experienced as a student nurse that influenced your decision making during this experience.
Describe how this experience could have been handled differently.
Decker’s (Based on Johns Work) Decker’s (Based on Johns Work)
1. Talk to me about the problem your patient was having
2. What was your main goal during this simulation?
3. Tell me what influenced your actions during the scenario.
4. Talk to me about how this experience made you feel and how satisfied you are with the actions you initiated?
5. Talk to me about how your personal values and beliefs influenced your actions during this experience.
6. Talk to me about the knowledge and skills you have that helped you provide patient care during this simulated experience.
7. Talk to me about experiences you have had that influenced what you did during this scenario.
8. What would you do different if we went back into the patient’s room and repeated the scenario right now?
Factors Identified by Student Groups as Affecting Critical and Reflective Thinking During a Simulated Learning Experience
Factors Identified Percent of Groups a
Personal Response to Stress 50%
Perceived Self-Confidence 25%
Skills Competence 25%
Urgency of Task 17.8%
Experiential Knowledge 17.8%
Theoretical Knowledge 14.3%
Potential Legal Implications 10.7%a (N=28)
Decker, 2007
Additional Factors IdentifiedAdditional Factors Identified
• having tunnel vision (fixations) or focusing inappropriately on past experience,
• being resistant to change or having a defensive attitude,
• having poor communication skills,
• the inability to access appropriate resources both technical and human, and
• the learner’s cultural background.Decker, 2007
Summary: ReflectionSummary: Reflection
Can be learned
Sufficient Time
Worthy experience Active experiential learning Clinically relevant
Learn by:• building knowledge on existing knowledge
• discovering what they know & what they do not know
Insight
Reflective ThinkingReflective Thinking
Learning from reflection is not
automatic –
It demands active involvement in clinical
experience and guidance
ReferencesReferences
AACN, (2005). Faculty shortages in baccalaureate and graduate nursing programs:
Scope of the problem and strategies for expanding the supply. AACN: Washington
Boud, D., Koegh, R., & Walker, D. (1985). Promoting reflection in learning: A model.
In D. Boud, R. Keogh & D. Walker (Eds.), Reflection: turning experience into
learning (pp. 18 – 40). London: Kogan Page.
Clarke, S. P., & Aiken, L. H. (2003). Failure to rescue: Needless deaths are prime
examples of the need for more nurses at the bedside. American Journal of Nursing,
103(9), 42-47.
Del Bueno, D. (2005). A crisis in critical thinking [Electronic version]. Nursing
Education Perspectives, 26(5), 278-282.
Decker, S. (2007). Integrating guided reflection into simulated learning experiences. In Jeffries, P. R. (ed), Simulation in nursing education from conceptualization to evaluation. New York, NY: National League for Nursing.
Dreifuerst, K. T. (2009). The essential of debriefing in simulation learning: A concept analysis. Nursing Education Perspectives, 30(2), 109-114.
ReferencesReferences
Finkelman, A. & Kenner, C. (2007). Teaching IOM: implications of the IOM report
for nursing education, American Nurses Association, Silver Spring, Maryland.
Glaze, J. (2002). Stages in coming to terms with reflection: Student advanced nurse
practitioners’ perceptions of their reflective journeys. Journal of Advanced Nursing,
37(3), 265–272.
Jeffries, P. R. (2007) . Simulation in nursing education form conceptualization to
evaluation. New York, NY: National League for Nursing.
Johns, C. (1995). Framing learning through reflection within Carper’s fundamental
ways of knowing in nursing. Journal of Advanced Nursing, 22(2), 226–234.
Johns, C. (1996). Visualizing and realizing caring in practice through guided reflection.
Journal of Advanced Nursing, 24(6), 1135–1143.
Mezirow, J. (1981). Transformative dimensions of adult learning. San Francisco:
Jossey-Bass.
ReferencesReferences
Murphy, J. I. (2004). Using focused reflection and articulation to promote clinical
reasoning: An evidence-based teaching strategy. Nursing and Health Care
Perspectives, Nursing and Healthcare, 25(5), 226–231.
National League for Nursing (NLN). (2005, May). Position statement: Transforming
nursing education. Retrieved July 9, 2006, from
http://www.nln/aboutnln/PositionStatements/transforming0520005.pdf
Nehring, W. M. & Lashley, F. R. (2010). High-Fidelity Patient Simulation in Nursing Education. Sudbury, MA: Jones and Barlett Publishers.
Paget, T. (2001). Reflective practice and clinical outcomes: Practitioners’ views on how
reflective practice has influenced their clinical practice. Journal of Clinical Nursing,
10(2), 204-214.
Wong, F. K. Y., Kember, D., Chung, L. Y .F., & Yan, L. (1995). Assessing the level of
student reflection from reflective journals. Journal of Advanced Nursing, 22, 48-57.
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