Page Updated – 13/6/18

PDF HANDOUT – 7 Simulation Pearls

DEBRIEFING WORKSHOP – Workshop Handout

WORKSHOP ACTIVITY – Activity for Debrief workshop

VIDEO FOR WORKSHOP:

Start 1:13 – End 3:18

Key Debriefing Papers:

• Paper 1 – PEARLS (Eppich-2015)
• Paper 2 – No such thing as non-judgemental debriefing (Rudolf 2006)

 (1) Creating the Environment for Change and Learning

How to Create a Great Learning Environment

How to Facilitate Change

“Adult learners will change when they choose”

• What helps us facilitate change in our participants?

 ‘Unfreezing Theory’ can help us get some ideas of how to help our participants move forward with their learning

(1) Surprise (disconfirmation of prior knowledge) = change is more likely

(2) Feels ”bad” after/during simulation = change is more likely

(3) Psychological Safety = change is more likely

There seems to be a conflict between “Surprise” / “Feeling bad” and “Safety”

Comfort v Discomfort – we have to strike a balance in this for optimum learning

How to Create a Platform for Change

• Knowing the instructors are in control can create a platform for change 
• The Students should be made to feel of value and importance by the instructors. 

Ways to Create Trust with Your Learners 

• Make a Confidentiality Contract (sends the message that this session is not an assessment)
• Create a Safe Environment for Learning
• In order to suspended disbelief in simulation “reality” set up the session to create the best fidelity that you can. Despite your best efforts you won’t always succeed in creating “adequate” realism
• Participants may feel awkward and surprised and therefore ‘make mistakes’ – tell them this is ok!
• Our Basic Assumption must be that all participants are capable, want to do their best and are looking to improve (this in some form should be stated at the outset)
• Show the Up-most Respect for learners
• Courtesy at all times
• Curiosity about all participants thoughts and comments
• Give participants (and facilitators) time to think: there should be space for reflection
• A good introduction can take up to 10% of the simulation session time but is an investment

(2) Where does Simulation fit in?

Bloom’s Taxonomy – Simulation operates above the level of a lecture (at the level of application)

Therefore, we need to avoid ‘lecturing’ in our debriefs!

(3) Special Challenges

Suggested Roles of a Simulation ‘Team’

• Course Director Role – Manage Schedule (stick to time), Manage People (the go to person), Hands on involvement
• Other Roles – Actors, Technical, ‘Confederate’ Nurse, Observers, Debriefer and Instructor Feedback for Debriefers

(4) Debriefing

Definition:   “A conversation between two or more people to review a real or simulated event in which participants analyse their actions and reflect on the role of thought process, psychomotor skills and emotional states to improve or sustain future performance”

Important Rules

Be Yourself as a debriefer but at the same time embrace feedback to improve you debriefs.

Use tested methods such as advocacy and enquiry.

Overview of the advocacy and enquiry model – Click Here

Educational Theory behind Simulation and Debriefing

Basis of Simulation is Educational Theory (It is a Solid Foundation)

• Kolb’s Model  – Click Here
• Bloom’s Taxonony (see above)
• The Ladder of Inference – Click Here
• Lewin’s Unfreezing Theory of Change (see above)

Gaining Debrief Expertise

Requires regular practice and on-going development including feedback from your colleagues

What are Frames?

Identify the Learners “FRAMES” – these is the knowledge or experience behind the actions and results seen in the simulation.

The concept of Frames is illustrated below:

Organising the Debrief

• Give the participants time to think during the debriefing

• Divide into phases:

• Reactions
  • All participants should speak – identify emotions / upset participants
  • Get the case facts on the table
  • Preview your Objectives

• Understanding
  • e.g. advocacy and enquiry
  • teaching
  • mix Clinical Pearls with Practice Pearls

• Take Home Points

How to start using this structure

• Use a template / action card and your notes to help structure the debriefing
• Identify the learner’s Frames by asking MORE about the ACTIONS and RESULTS.
• Ask in your own mind how did they come to their decisions?  
• Use key phrases to seek this information:
  

  “I saw you ___ and this resulted in ___” “I think that this___”  “What are your thoughts?”

The Second Debriefer’s Role

• Add to the richness of learning during the debrief
• Place untimely points or questions in the “white board” – questions that cannot be answered at time are written on the board – 2^nd debriefer can facilitate these questions being answered
• May help spot and debrief upset participants
• Can often be good for bouncing ideas and getting discussion flowing
• The ideal person to present the “facts of the case”
• This role can be active or passive depending on needs
• This person can provide support and feedback to the primary debriefer

How do you set up the Room?

Our Suggestion – Use an open plan (no tables) Circle or Semicircle with Debriefers across from each other.

This can improve communication between debriefers and help involve all the participants in the discussion.

Good Judgment 

What are the Qualities of the “GOOD JUDGEMENT” Debriefer?

Buzz Words – Debriefing Phrases

• Avoid the use of “but” (avoid the “S**T sandwich” if you can – this is easier said than done)
• When stating a positive observation add “because” (re-enforce what was done well!)

• The table below should give you some ideas for your next debrief:

(5) Pros of Simulation

(6) Managing an Upset Participant 

Try to be on the look out for upset participants (and/or observers).  Identification of the ‘upset participant’ is a key reason to ensure that the all those involved in the scenario talk during the initial reactions phase of the debriefing.  Emotive Simulations can produce strong reactions because of memories of traumatic past experiences and sometimes emotions are conjured up for no apparent reason at all… While you can’t “fix” an upset member of the group, the emotion displayed can turn to a very constructive discussion and lead to deep learning for all.  Stick to the following rules to keep your simulation ship afloat:

Rule 1 – Always Play Fair

• Participants must know
  • • • • (1) Who they are
        • (2) Who others are
        • (3) Where they are
        • (4) What is the issue
• Create a backstory – It MUST be a plausible scenario!

Rule 2 – Set Learner Expectations and prevent Rule “violations”

• Prevention of ‘upset’ participants – orientation to environment and agreement on rules (contract)
• Ground rules for conduct and behaviour of both participants and facilitators
• Be consistent with the rules in the Learning Environment and Simulation Centre

Rule 3 – Identify and Manage common reactions

• External reactions (e.g. it’s the Simulation Centre’s fault “it is unfair”)
  •  Simulation Complaints – don’t try to defend: best to sympathise and empathise
    • To avoid this problem give a backstory and realistic scenario
    • Redirect to Real world Focus and what is worth talking about

• Internal Reactions (e.g. “I messed up”)

• • Direct Engagement  – Normalise – it’s happened before, simulation is hard
  • Students can support one another; give the learner choices (talk, move on etc.)

• • Indirect Engagement – change the focus and allow participant to regain composure
  • Follow up and privately deal with any major or on-going issues

(7) Creating Simulations

Simulation Development

Develop Learning Objectives

• A key phase in development and running  simulations – always start from the basis of LEARNING OBJECTIVES
• Think S.M.A.R.T.  – Specific, Measurable, Attainable, Relevant, Time-bound

When setting goals focus on “The Performance Gap” = Observed (Current) Performance v Desired Performance

Designing a Course

• Make a needs assessment – who are the learners? what are your Learning Objectives?
• Course Logistics – where, when, how, cost
• What is the best style of simulation?
  • Consider adopting a “pause and discuss” style of scenario if application of new clinical/technical knowledge is your goal (i.e. for junior learners immersive scenarios are no always necessary to create ‘challenge’ and ‘change’)
• Scenarios and Assessments – Based on M&Ms, Online or Re-formed cases? / MCQ, practical (or no assessment)?
• Course Evaluations
  • Use the SHARP and OSAD tools to help improve your future sessions

Take Homes

(1) Quality Feedback is a key aspect of learning in adulthood (participants are usually seeking feedback)

(2) Be interested in your learners – they will value this and are more likely to benefit from the simulations

(3) Invest time in preparation and introductions to the simulation environment

More on Debriefing Simulation

Click Here

Simulation Resources

Australian Society for Simulation in Healthcare (ASSH)

EM SIM CASES

Centre for Medical Simulation at Harvard

EuSim Group

ICU – SIM at the Alfred

Injectable Orange

MobileSim

National Health Education and Training in Simulation

Neuro-Sim

Simulation and Clinical Skills Victoria

Society for Simulation in Healthcare

Society in Europe for Simulation Applied to Medicine