*Until We Reflect

Report
The F. Marie Hall SimLife
Center
Sharon I. Decker, RN, PhD,
ANEF, FAAN
Professor, Director of Clinical
Simulations
Covenant Health System Endowed
Chair in Simulation and Nursing
Education
• Identify
the goals of debriefing.
• Discuss
the elements of debriefing
that improve outcomes.
• Identify
various approaches to
debriefing.
• Discuss
the process of debriefing.
Our students
“ It isn’t that they can’t see the solution. It is
that they can’t see the problem.”
G. K. Chesterton
“They don’t know what they don’t know”
◦ “Better learning is associated with
improved teaching techniques”
[simulation]
Dunn, 2004
◦ Teaching techniques that are
evidence based and applied
appropriately facilitate successful
learning (and patient outcomes).
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Experience alone does not guarantee
learning nor clinical competence
Reflection promotes the transfer of
experience to learning and knowledge
Therefore: Learning is dependent
upon the integration of experience
(simulation-based and patient
centered) and reflection.
◦
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Conscious consideration of the meaning
and implication of an action
◦ Assimilation of:
 Knowledge (Concepts)
 Skills
 Attitudes (Values & beliefs)
With pre-existing knowledge

Reflexio (Latin)
◦ The act of
bending back
A “wave motion
or energy”
Reflectivity
dependent on:
 Angles of
incidents
A “wave motion
or energy”
Reflectivity
dependent on:
 Texture of the
reflective
surface
A “wave motion
or energy”
Reflectivity
dependent on:
 Wavelength

Reflection - Initiated
through Questioning
…You lead me on by means
of things I know, point to
things that resemble them,
and persuade me that I
know things that I thought I
had no knowledge of.”
(Quotes in Xenophon’s “Economics”)

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Active, persistent, and careful consideration
 Learning is dependent upon integration
of experience with reflection
Reflection promotes understanding of
relationships

Reflection-on-action
◦ Reflecting after – thinking through

Reflection-in-action
◦ Being aware
◦ Reflecting while doing
 “They ‘feel’ where the music is going and adjust
their playing accordingly.” (pg. 30)

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
Knowing-in-action (Expert)
Professional knowledge
Skills competence
Applying theory while problem solving
Responds or “makes new sense” of
uncertain, unique situations

“Think like a nurse”
Reflecting
(Reflective Observation)
Experiencing
(Concrete Experience)
Learning Cycle
Thinking
Applying
(Active Experimentation)
(Abstract Conceptualization)
Reflecting
(Reflective Observation)
Learning Cycle

Barriers
◦
◦
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Previous learning
Fixations
Socialization &
Organizational culture

Outcomes
◦ Heightened selfconfidence
◦ Empathy
◦ Understanding
(Knowledge)
◦ Improved critical
thinking
◦ Better patient care

Requires
 Active involvement
 Realist environment
 Authentic experience
 Assistance (guidance)
 Time to reflect

Can be taught
Learners expanded their repertoire of
possible solutions
Boyd & Fales, 1983
Henderson & Johnson, 2002
Learning from
reflection is not
automatic –

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It demands active
involvement in
clinical experience
and guidance
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

Difficulty developing reflection

Learner may have a distorted “view”
 Could lead to repeating mistakes
 Learners may only view the negative
 Fixations

Outcome influenced by facilitator’s
skills
Boud, Keough, & Walker, 1985; Boud, 2001;
& Paget, 2001
If facilitators interject their
feedback prematurely learners
stop reflecting, lose confidence,
and become dependent on
faculty
Westberg & Jason, 2001

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Set expectations (outline the process)
Facilitate according to level of engagement
Include “quiet” learners
Integrate instructional points
Reinforce
Identify deficiencies
Correct errors
Summarize & Review improvement
strategies

Confidential

Review objectives and expectations

Professional courtesy

Supportive not judgmental

Listen
◦ No interruptions
◦ Respect
◦ Don’t talk about anyone not present
◦ Positive before negative

Depends on
◦ The objectives
◦ The learner
◦ The facilitator
◦ The experience
◦ Time allowed for the process
◦ Relationships between participants
 High – “debrief themselves” [Critical
Reflectors]
 Intermediate – “assistance” needed to
analyze the experience [Reflectors]
 Low – learners demonstrate little initiative
[Non-Reflectors]

Environment
◦ Safe – non-threatening, trustful
◦ Circle – or modified according to
objectives
◦ Private
◦ Time Varies – equal to or longer then
the scenario
•
•
•
Be proficient with the equipment
Do not show a segment unless it is to be
discussed
Show only 3 to 4 critical segments
 “This segment occurred … discuss what you were
thinking as you…”
• Show the segment
• Pause – all the learner to self-critique

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The
The
The
The
participants
facilitator’s expertise
experience
impact
The recollection
The timing

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Encourage self/team analysis
Identify different ways of handling event
next time

Correct errors

Promote reflective thinking

A process in which after an experience the
learner is lead through a purposeful
discussion related to the experience
 Lederman, 1992; Fanning & Gaba, 2007

During
◦ “In-Simulation” – “Simulation Suspended”
 Error in management or 30 seconds without action
 Failure to perform a critical action
◦ Frozen
Van Heukelon, Begaz, & Treat, 2010
 Emphasize teaching
 Defuse a deteriorating situation
 Limit embarrassment
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After
 Decker, Gore, & Feken, 2011
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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

Immediately after the experience
Can be integrated with debriefing

Self- Reflection – post experience
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Beginning – Reactive phase
◦ Emotional reactions

Middle - Analysis
◦ Analysis and critique
◦ Correct any errors not recognized

Summary ◦ Summarize the simulation
◦ Translation to practice

Observers – Peers
◦
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Explicit instructions
Set the ground rules
Needs to be guided
Need a tool while observing
Do not participate in the reactive phase
◦ During analysis – could be the third person in
circular questioning
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Socratic Questioning –
Guided questions – Strategically integrated
“what if’s”, students find this difficult
◦
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Requires active learning
Encourages logic – making connections
Facilitates critical thinking
Integrated and/or during debrief
Lambright, 1995; Schoeman, 1997
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Socratic Questioning
◦ What did you experience?
◦ Analyze how you performed overall.
◦ How would you change your performance?
◦ How can you apply knowledge and skills for
this simulation to an actual patient care
situation?
Alpha
Delta (Based
on standards)
Gamma
Examples of
good action
What we would
like to change
How we would
change
What was the outcome
What could have occurred
when you initiated CUS? if CUE had not been
initiated?
Recognize performance
gap
Strategies to minimize
performance gap
 Phase
Gather 25%
Analyze 50%
Goal
Actions
Actively listen to participants
understand their perspectives
Request narrative - Clarify
“How did it make you feel?
Clarify - Facilitate reflection
Review events - Analyze
Report Observations
Correct
Ask probing questions
“What were you thinking
when…”
Summarize 25% Facilitate identification
Plan strategies
Verify and Summarize
“Describe two things you need
to work on…”
WISER http://www.wiser.pitt.edu/

Uses:
◦ reflection-in-action, reflection-on-action, and
reflection-beyond-action
◦ Six phases – Engaging, Exploring, Explaining,
Elaborating, Evaluating, and Extending
◦ Focuses on learning
◦ Uses concept mapping

Ask how one participant thinks another
participant felt in a situation
◦ Example: “Jackie, how do you think Joe felt when you
didn’t listen to his suggestions during the simulation?”
Or

Ask a third person to discuss a behavior that
occurred between other participants
◦ Example: “Jenny, what did you observe related to the
interaction between Jackie and Joe?”

“Debriefing with Good Judgment” –
(Advocacy-Inquiry)
Debriefing
leads to new
frames
Frames
Debriefing
changes
later actions
Actions
Results
http://www.harvardmedsim.org

Advocacy – Inquiry
◦ “I noticed ….”
 “you did not double-check the dose of the medication.
Without the double –check”
◦ “I’m concerned…”
 “that the patient is at more risk of getting the wrong
dose.”
◦ “I was wondering…”
 “what was on your mind at the time?”
Depends on learners and
objectives
 [Example]

◦ Review recorded performance
(A-V)
◦ Peer Debrief
◦ Self-Debrief “self-assessment”
 Debrief checklist
 Written Journal
 Web-based
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Research needed
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“how to promote reflection”
“when and how often”
“what are the most effective approaches”
“whom should be included in the process”
“how to structure – what tools/techniques”
◦ Measurement tool
 Debriefing Assessment for Simulation in Healthcare
(DASH)
 http://www.harvardmedsim.org.debriefing-asssessmentsimualtion-healthcare.php
Evaluate educational effectiveness
Assessment of debriefing - DASH
Meeting of educational objectives
Scenarios
Videos of simulations and debriefing
All simulated experiences should
include a planned debriefing
session aimed toward promoting
reflective thinking
Guidelines and toolbox being
developed
Websites
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Simulation Innovation Resource Center, National League for Nurses http://sirc.nln.org/
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TeamSTEPPS available at http://teamstepps.ahrq.gov/
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QSEN Teaching Strategies incorporating simulation available at
http://www.qsen.org/view-strategies.php
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World Health Organization: Patient Safety Tool Kit available at
http://www.who.int/patientsafety/education/en/
Websites
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Army’s After-Action Review – Summary: available at
http://www.au.af.mil/au/awc/awcgate/army/tc_25-20/chap1.htm
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http://www.wpahs.org/education/star-center/course-catalog/star-courses/debriefing-tools
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http://collaborate.uw.edu/educators-toolkit/debriefing-tools.html
Debriefing Guide for Facilitators
furcs.flinders.edu.au/.../CHSA%20sim%20toolkit/...

DASH
http://www.wpahs.org/sites/default/files/file/D11DASH-handbook2010FinalRev2.pdf

The Observational Structured Assessment of Debriefing Tool
http://www1.imperial.ac.uk/resources/CFE7DECB-8FE7-437C-8DAA6AB6C5958D66/debriefingosadtool.pdf

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