SIMQ: The Debrief and its Importance in the Simulation Learning Experience

From the Desk of Carol C. Dudding, PhD, CCC-SLP, CHSE

This article is part of an ongoing series of articles on simulations in healthcare, specifically in the Allied Health Professions. The SimQ format, allows us to explore the technological as well as pedagogical aspects of simulation for clinical education through the words of the experts.  It is anticipated that the audience will include university faculty, clinical educators, and professionals with interest in the use of simulations to enhance the clinical education of our students and practicing professionals. These articles are intended to address the needs of those considering the use of simulations, and those with varying experiences and level of skill.

In this SimQ article, we will focus on a specific aspect of the simulation learning experience; the debrief. The discussion will address the importance of debriefing as part of the learning process. Research and evidence-based practices for debriefing will be discussed.

Erin S. Clinard, M.A., CCC-SLP is an instructor and the Coordinator of the Online MS SLP program in the Department of Communication Sciences and Disorders at James Madison University.  She is currently a PhD candidate in CSD with a focus in pediatric neurodevelopment and clinical education. Erin has been an SLP for 14 years, working predominantly in acute care medical centers and outpatient clinics.  Her areas of clinical specialty include the management of infants in the NICU, pediatric feeding and swallowing, and pediatric aural habilitation. Erin has been a clinical educator for over 10 years and is passionate about the scholarship of teaching and learning.  Specifically, examining approaches, such as simulation, to develop students’ clinical decision-making, critical thinking, and ability to practice interprofessionally.

 

Carol C Dudding, PhD, CCC-SLP, CHSE
Contributing Editor

SIMQ: The Debrief and its Importance in the Simulation Learning Experience

Erin, it is so good to have you with us. Please tell us about yourself and your interest in simulations.

I have been a speech-language pathologist for over 14 years. I am a faculty member and the Coordinator of the Online MS SLP program at James Madison University in Harrisonburg, Virginia.  Currently, I am finishing up my PhD in speech-language pathology in the area of pediatric neurodevelopment and clinical education.  As a clinician, I worked in acute care settings, outpatient pediatric clinics, and the Neonatal Intensive Care Unit (NICU) with medically-complex and high-risk infants.  I have always been passionate about working with complex patients and collaborating interprofessionally to provide the best patient care. I also supervised graduate students and new clinicians.  I often observed that students lacked the foundational knowledge and confidence to work with medically-complex populations, which is what inspires my research.

I am interested in examining innovative approaches (particularly simulation) to support students’ development of clinical decision-making and improve foundational knowledge and confidence.  Simulation has been so successful in other fields, such as nursing, and is a risk-free option for students to gain experience with high-risk and low-incidence populations prior to entering into the field.  

1.  I agree wholeheartedly. We have shared research in some earlier articles on the topic of supporting students' development and confidence through the use of simulation.  Interested readers are encouraged to read those articles. What can you share with us about your current research?

My current research has been a collaboration between myself and the JMU Nursing Simulation Laboratory.  I am examining knowledge and confidence outcomes for management of a medically-complex infant, following a high-fidelity simulation.  Along with other NICU specialists, we designed a case study for the pediatric dysphagia course that I teach at JMU. The nurses, all Certified Health Simulation Educators, and I worked together to program and run the scenario using Super Tory, a high-fidelity manikin from Gaumard Scientific.  One of the RNs was an embedded participant performing the role of the bedside nurse to further enhance fidelity. SLP graduate students were teamed up and participated in the simulation to assess an infant’s oral feeding readiness and performance with an oral feeding trial. The response from students was so positive and there were positive changes in confidence as a result.  They were especially positive about the debriefing and its impact on their learning in the simulation. I look forward to continuing this collaboration to further expand this simulation into an interprofessional experience, and to create additional manikin-based simulation experiences for both nursing and allied health students.

2.  No doubt your research will help to move the field forward.  What excites you most about the use of simulations in clinical training in allied health professions?

Thank you. I love the potential that simulation offers us as clinical educators.  The opportunity to provide students with hands-on opportunities to work with high-risk or low-incidence populations is so exciting.  Through simulation, we can ensure that no matter where students go to school they can learn to assess and treat patients across the spectrum of disorders.  I find great value in the fact that simulation provides students with the opportunity to learn through failure.

3.  What do you mean, “learn through failure”?

Because there is no real patient’s health or well-being at stake, students can test out different approaches to an evaluation or intervention and learn through making mistakes or testing their hypotheses.  This type of risk-free learning is so valuable. Students can see the impact of their decisions and evaluate better, more effective, or more efficient ways to ensure the highest quality of patient care. For both clinical educators and students, simulation allows for opportunities to develop skills and explore different approaches with no risk to a patient.  For students, actually seeing what does and does not work has a lasting impact. This learning then transitions to their service delivery in other settings and with real patients.

4.  What do you see as the current barriers to simulation use?

While more professionals are beginning to recognize the benefit and potential of simulation-based education in allied health professions, I think one of the greatest barriers is a lack of knowledge about simulation, including the simulation process, technologies, and best practices.  I also think that accessing simulation facilities and experts can be challenging. Even though many universities have simulation facilities somewhere on their campus, and even though there is an increased focus on interprofessional education across health professions, it can be challenging to establish mutually-beneficial collaborations.  There are so many options and so much potential though, often it just takes some creative thinking and finding the right partners.

5.  In other articles of this series, we learned that there is more to simulations than just the simulation itself. Can you tell us more about the components of the simulation process from the perspective of a clinical educator?

I’ve met people who are skeptical of simulation in SLP and other allied health clinical education, and I have heard it referred to as a just something that students do on their own; a “lazy substitute” for experience with real patients.  Simulation is a teaching technique that must include three essential components: a prebriefing, the simulation or scenario, and a debriefing.

The first step is prebriefing.  This is much like any meeting we have with a student prior to a clinical experience.  It is critical for establishing expectations and preparing students for what they will encounter in the simulation.  Students can think through what they might expect, ask questions, develop an initial hypothesis, and formulate a plan.  Then students complete the simulation scenario in which they follow through with their plan, collect data and information that will help them make a diagnosis and determine goals, treatment approaches, recommendations, etc.  Finally, and most importantly, is the debriefing. Debriefing happens following the simulation scenario and is the process of providing feedback and engaging students in self-reflection and critical thinking. During the debriefing, students apply their learning and experience to consider what went well and what they would change about what happened in the simulation.

6.  So I understand that you have a specific interest in the debriefing process. How did that come to be?

I am very interested in the debriefing because this really is the heart of the simulation process.  Honestly, it was what I always have believed to be the heart of clinical education as well. Those light bulb moments, when students made the connection between what they know and what they do, often happened when they would reflect on a clinical experience.  Through reflection, students are engaged in critical thinking and start to develop the ability to understand why certain decisions are better than others. They learn how to justify their choices and recognize the implications of those choices. Debriefing is where students learn to think like clinicians.

My interest in debriefing really stems back before I even started with simulation. As a clinical educator, I was always exploring ways of engaging students in their learning so that they were able to problem solve and think through assessments and sessions to make the best clinical decision.  This is a real challenge for many students, but you can see them learning to make the connections and apply their classroom knowledge and limited experience. With simulation, we can amplify this experience and through debriefing a simulation students can make connections to future clients.

7.  As you mention, the process appears to have a lot in common with good practices in clinical education, in general. The debriefing appears to be key to student learning.  Is there evidence to support the importance?

Much of the simulation literature in nursing suggests that debriefing is essential and critical to the learning process.  However, because the simulation is a process that includes multiple components (prebriefing, simulation, debriefing) it can be difficult to isolate the effects of each of those components.  One study that accomplished this is Shinnick, Woo, Horwich, and Steadman (2011),  isolated the debriefing from the other components. Their findings support that learning happens in the debriefing.  This is a critical finding. Simulation is not going to be effective and students will not learn if they are not engaged in quality debriefing.

8.  What makes a “good” debriefing session?

The key to good debriefing is creating an environment that is open and supportive.  The clinical educator acts as a facilitator so that students can process their experience and critically think through their thoughts and feelings that influenced their actions and decisions so that they can consider how they might change their behaviors in a future experience. Students need to feel safe to ask questions and the clinical educator needs to be able to provide direct, action-specific feedback to shape their understanding so that they can correct any errored thinking.

9.  Are there debriefing models available for me to use?

Providing an open and supportive space for students to reflect, while also providing critical analysis or judgment of their clinical performance is a challenge, even for seasoned clinical educators.  Having a model or framework to guide the process of providing feedback and facilitating students’ reflection is valuable for educators in debriefings.

There are many models of debriefing.  To name a few:

• The 3D Model (Defusing, Discovering, Deepening) by Zigmont, Kappus & Sudikoff (2011)

• The PEARLS (Promoting Excellence And Reflective Learning in Simulation) model by Cheng et al. (2016)

• Debriefing with Good Judgment by Rudolph et al. (2006)

These models can help establish consistency across faculty who are facilitating debriefings and establish a predictable sequence for the debriefing, reducing student apprehension and improving understanding of the expectations in debriefing.  

10.  Where can I find more information?

The nursing and medical literature are great places to look to learn more about debriefing.  A few great resources to get started are:

Cheng, A. et al. (2014). Debriefing for technology-enhanced simulation: A systematic review and meta-analysis. Medical Education, 48, 657-666.

            Fanning, R. M. & Gaba, D. M. (2007). The role of debriefing in simulation-based learning. Simulation in Healthcare, 2(2), 115-125.

Gardner, R. (2013). Introduction to debriefing. Seminars in Perinatology, 37, 166-174.

Sawyer, T. et al. (2016). More than one way to debrief: A critical review of healthcare simulation debriefing methods. Society for Simulation in Healthcare, 11(3), 209-217.

11.  Are there workshops or training sessions available?

There are trainings available. You will note that they are not specific to allied health professions but the principles are easily applicable.  Here is a list of some resources:

• Harvard Center for Medical Simulation offers an advanced debriefing course https://harvardmedsim.org/course/advanced-debriefing-course-adc/

• The Global Institute for Simulation Training offers training and webinars http://www.simulationtraining.org/

• The International Nursing Association for Clinical Simulation and Learning (INACSL) has an annual conference, regional workshops, and webinars.  They also provide valuable resources regarding best practices in simulation. https://www.inacsl.org/

• The National League of Nursing (NLN) Simulation Innovation Resource Center (SIRC) offers training and courses, online and in person http://sirc.nln.org/

• The Society for Simulation in Healthcare (SSH) hosts several conferences and has workshops http://www.ssih.org/

• Laerdal, one of the companies that manufacture simulation manikin technology offers workshops: https://www.laerdal.com/us/services-and-programs/sesn/sesn-workshops/

12.  Which model do you use?

The model that I am most familiar with and have used in my research is Debriefing with Good Judgement (Rudolph et al., 2006).  This is the model adopted by the Nursing Simulation Laboratory at JMU and the model that I have used in my research. Debriefing with Good Judgment provides a framework for a debriefing that does not gloss over or avoid discussing mistakes or errors, yet still creates a supportive space for reflective practice.  Often, in order to avoid being judgmental or for fear of students becoming defensive, educators can end up airing on the side of caution and not directly sharing critical judgments or observations. This is problematic because learning happens through sharing these observations and judgments and if they are not shared or addressed then students may continue to make the same errors, risking patient care.  Good judgment recognizes this and focuses on meaning-making. The focus is on understanding the assumptions, biases, or thought processes that led to certain decisions and using that as the foundation for learning and shaping clinical behavior.

Another great thing about the Debriefing with Good Judgment model is that the authors, along with others in the Harvard Center for Medical Simulation developed a set of tools, called the Debriefing Assessment for Simulation in Healthcare (DASH), for evaluating and rating the techniques and strategies used by a debriefer in a debriefing.  You can find this tool and information about training to be a DASH rater here: https://harvardmedsim.org/debriefing-assessment-for-simulation-in-healthcare-dash/

13.  What do you like about it?

I like that the Debriefing with Good Judgment model recognizes the importance of discussing errors and correcting students’ thinking in order to help them develop and learn the skills we need them to in order to be effective professionals.  The facilitator is the content expert but has their own framework, experiences, and biases that impact how they think about or would approach a particular clinical situation. With this in mind, the debriefer engages students in an advocacy-inquiry conversation by making a specific observation or identifying a specific action during the simulation and then asking students to share about what they were thinking or feeling during those moments in the simulation.  This advocacy-inquiry approach allows the facilitator the opportunity to understand the students' thinking and how their thinking led to certain behaviors or actions. This can help the debriefer identify errors in thinking or understanding that may need to be discussed or corrected in order to improve their performance. Students can then take that new understanding into future simulations or clinical situations.

14.  Do you ever modify your debriefing approach?

Absolutely.  As a debriefer, my role is to facilitate student learning and allow them the space to reflect, ask questions, and discuss their experience.  While the Debriefing with Good Judgment model provides a structure and approach for doing this, it is not a script to follow.

For example, it may happen that you have a challenging student that may require individual debriefing or remediation to ensure that they have the requisite knowledge and skills before advancing in the curriculum.  Or you may have a student who has significant errors in their understanding of content or clinical thinking that must be addressed. It may be beneficial to use a video recording of the simulation to guide the discussion, refer to the literature or resources to discuss what the evidence supports, etc. to be sure that students are mastering the skills and competencies outlined in the simulation objectives.

15.  How have clinical educators viewed the debrief?

Most of the clinical educators that I have worked with in simulation, recognize and embrace debriefing.  They find that debriefing in simulation has improved their debriefing of more traditional clinical experiences because they are more focused on reflection and understanding student thinking in order to more effectively shape their behaviors.  It does take training though, not all clinical educators know how to create a safe space and facilitate reflection.

16.  How about students? What do students think about the debriefing process? Are they aware of its importance?

Students report sometimes feeling weird or silly at first when asked to reflect on their learning, but as they begin talking and building off what each other says it really develops into a very rich discussion.  Students consistently identify the debriefing as the most valuable part of the experience because it is their opportunity to clarify their understanding, consider what they did well and what they might do differently the next time.  Students love the hands-on learning and getting to apply their knowledge in simulation and recognize that debriefing is often the step in the process that is the most influential in their learning.

17.  Your research sounds so interesting. What are some lessons from your experiences with debriefing?

Thank you, I am excited about my line of research and making simulation in clinical education accessible to more and more people.  By conducting discipline-specific research we can enhance our own evidence-based best practices in the use of simulation with the populations that we serve as allied health professionals.

Some of the lessons that I have learned are to really be quiet and listen.  I have learned that students are paying attention in our classes and retaining the information, but that they do not realize or feel confident in their own knowledge until we allow them the space to use what they have learned and apply it.

18.  What are the next steps for you in your research and use of simulations?

I have so many project ideas it is hard to decide what is next, but I really want to focus on examining the effects of quality debriefing on critical thinking and clinical decision-making. With this, examining a systematic approach to training allied health clinical educators to be effective debriefers.  Specifically, with simulation, I am excited about moving forward with the nursing simulation laboratory and developing a series of interprofessional simulations that involve nursing, speech pathology, and other health disciplines.

19.  That’s exciting. What do you hope people will take away after reading this article?

I really hope that readers will recognize that simulation is more than a technology.  It is more than sitting students in front of a computer or a piece of equipment and expecting them to learn to think critically.  Simulation is a process that connects what students learn in the classroom with opportunities to apply that learning in a safe, risk-free, hands-on environment.  Most of all, I hope that readers walk away with an appreciation for the importance and power of the debriefing. The debriefing should be well-designed and systematic; it should engage students, challenge students, encourage students.  A debrief requires training, skill, and practice to effectively facilitate deep reflection and enduring learning.

References

Cheng, A. et al. (2014). Debriefing for technology-enhanced simulation: A systematic
review and meta-analysis. Medical Education, 48, 657-666.

Fanning, R. M. & Gaba, D. M. (2007). The role of debriefing in simulation-based learning. Simulation in Healthcare, 2(2), 115-125.
 
Gardner, R. (2013). Introduction to debriefing. Seminars in Perinatology, 37, 166-174.
 
Sawyer, T. et al. (2016). More than one way to debrief: A critical review of healthcare simulation debriefing methods. Society for Simulation in Healthcare, 11(3), 209-217.