Transcript Cueing , Questioning, Debriefing, & Reflection

Sharon Decker, RN, Ph.D., ACNS-BS, CCRN, ANEF
The Role of Debriefing and
Guided Reflection in
Simulation
Objectives
• Compare the strategies and models of debriefing and guided
reflection.
• Explore the integration of debriefing and guided reflection
during simulation.
Introduction: 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
Health Educators’: Challenge #1
How have these changes impactedhow we deliver education?
competencies required for our discipline?
Introduction
Challenges for the Health Educator
“requires complex, sophisticated judgments and psychomotor
skills…” (p.128)
IOM, Crossing the Quality Chasm (2001)
Federal Committions
 Institute of Medicine (2004)
• recommended teaching environments
– Require demonstration of competencies in
patient-care delivery, evidence-based practice,
quality improvement, and informatics
Health Educators’: Challenge #2
New nursing graduates have difficulty
transferring knowledge and skills to the
practice setting
Clarke & Aiken, 2003
Del Bueno, 2005
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:
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 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
“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 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:
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:
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 Strategy
Unique teaching tool that requires the educator
to
● develop competencies with a new set of skills
● and be a risk taker.
Professional Charge for the Future
 Therefore, if we must reinvent
clinical teaching in practice
based learning environments
Could simulation
be one mechanism for
safe practice based learning?
Promoting Reflective Thinking
Experience alone does not guarantee learning
Need the integration of reflection
(Boud, Keogh, & Walker, 1985)
Simulation =
Patient Care Experience
+
Debriefing and/or Guided Reflection
Adult Learning Principles
Diverse Learning Styles
Visual (realism, fidelity of the environment)
Auditory (verbal responses)
Tactile (hear and lung sounds)
Kinesthetic (handling equipment)
Adult Learning Principles
Constructivism
Learning = process of constructing meaning
Educator functions as a collaborative facilitator
Includes experiential learning
Active engagement
Reflective thought
Reflection: 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 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 Framework
Kolb (1984)
• Learning enhanced through a synergistic transaction between
learner and the environment
Bandura (1977)
• Learning enhanced – self-confidence promoted with active learning
Reflection
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 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 Thinking
Enhances learning from experience
Helps expand clinical knowledge
Promotes reflective practice
Improves clinical judgment
Glaze, J. E. (2001)
Paget, T. (2001)
Murphy, J. I. (2004)
Reflective 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 automatic
demands active involvement in a clinical
experience (Teekman, 2000) and
guidance throughout the reflective process
(Johns, 1996; Tanner, 1999).
Barriers & Outcomes
of Reflective Thinking
Barriers
Outcomes
 Previous learning
 Heightened self-confidence
 Fixations
 Empathy
 Socialization (as a nurse)
 Understanding
 Organizational culture
 Better patient care
Environment and Tools
Environment
 Safe – non-threatening, trustful
 Circle
 Confidential
 Time equal to or longer then the scenario
Setting 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 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
Discussion
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 Responsibilities
Dual role – facilitator and instructor
Facilitator
guide learner
Self-discovery
Instructor
enhance understanding of “deficiencies”
Faculty 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 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…?”
Break
What is the difference between
Debriefing and Guided Reflection?
Debriefing
Debriefing
A process in which after an experience the
learner is lead through a purposeful discussion
related to the experience
Lederman, 1992; Fanning & Gaba, 2007
Debriefing: Purpose
Correct errors
Identify different ways of handling event next
time
Encourage self-assessment
Promote reflective thinking
Debriefing - When
During – (Frozen)
 Emphasize teaching
 Defuse a deteriorating situation
 Redirect
 Limit embarrassment
After
Facilitation 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 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 Models
Plus - Delta
Plus +
Examples of good behaviors
Delta –
Behaviors to improve on
Include both what and how
Debriefing Models
Advocacy – Inquiry
 “I noticed ….”
 “I’m concerned…”
 “I was wondering…”
Debriefing
Summary
Correct any errors
Video for
discussion
Guided Reflection
Guided Reflection
The process that allows practitioners to
uncover and expose thoughts, feelings and
behaviors
An active process of self-monitoring initiated
by a state of doubt or puzzlement occurring
during or after an experience
Guided Reflection: Purpose
Promotes insightfulness
Leads to discovery of new knowledge
New knowledge – to be applied in future
situations
Guided Reflection: When
Immediately after the experience
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
Guided Reflection: Models
Gibbs (1988)
Reflective Cycle
Action Plan
If it arose
would you do?
Description
What happened?
Conclusion
Feelings
what else
could you
have done?
What were your
thinking & feeling?
Analysis
Evaluation
What sense can
you make of
the situation?
What was good &
bad about
the experience?
Driscoll, 2000
The WHAT Model Of Reflection
WHAT?
Describe the event
Experience
Purposeful reflection
New learning
NOW WHAT?
Proposed action
SO WHAT?
Analysis the event
Discover what learning
emerges from the
reflection
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,
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,
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)
1.
2.
3.
4.
5.
6.
7.
8.
Talk to me about the problem your patient was having
What was your main goal during this simulation?
Tell me what influenced your actions during the scenario.
Talk to me about how this experience made you feel and how
satisfied you are with the actions you initiated?
Talk to me about how your personal values and beliefs
influenced your actions during this experience.
Talk to me about the knowledge and skills you have that helped
you provide patient care during this simulated experience.
Talk to me about experiences you have had that influenced what
you did during this scenario.
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
Personal Response to Stress
Perceived Self-Confidence
Skills Competence
Urgency of Task
Experiential Knowledge
Theoretical Knowledge
Potential Legal Implications
a (N=28)
Percent of
Groups a
50%
25%
25%
17.8%
17.8%
14.3%
10.7%
Decker, 2007
Additional 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
Discussion
As faculty how can we resolve these barriers?
Summary: 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 Thinking
Learning from
reflection is not
automatic –
It demands active
involvement in clinical
experience and
guidance
References
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.
References
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.
References
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.