Successful debriefing - best methods to achieve positive learning outcomes: a literature review

Instructor-led vs. peer-led debriefing in preoperative care simulation using standardized patients

BACKGROUND

Debriefing involves the active participation of learners to identify and close gaps in knowledge and skills. Varied debriefing methods are used in simulation, but no empirical studies have examined the effectiveness of peer-led debriefing in simulation using standardized patients. The purpose of this study was to compare the effects of two debriefing methods (instructor-led vs. peer-led) on nursing skills, knowledge, self-confidence, and quality of debriefing among undergraduate nursing students in South Korea.

METHOD

A nonequivalent control group pretest-posttest design was used. Fifty-seven third-year nursing students were randomly assigned to instructor-led (n = 26) or peer-led (n = 31) debriefing groups after a simulation of preoperative care. Structured questions and areas for discussion guided debriefing in both groups. Self-administered questionnaires were used to collect data on students' knowledge and self-confidence in providing preoperative care. Faculty evaluated students' nursing skills during pre- and post-simulation practice. Students evaluated the quality of the debriefings.

RESULTS

Nursing skills for preoperative care (p < .001) and the quality of debriefing (p < .001) were statistically higher in the instructor-led group compared to the peer-led group. There were no statistically significant differences in knowledge (p = .445) and self-confidence (p = .686). Knowledge and self-confidence from pre-test to posttest were improved in both groups.

CONCLUSION

The instructor-led debriefing showed improved nursing skills and higher quality debriefing. However, peer-led debriefing led by a non-trained peer also rendered positive results. Thus, peer-led debriefing may be considered a useful strategy for improving nursing students' self-confidence.

The utilisation of a structured debriefing framework within the pre-hospital environment: a service evaluation

Background:

Debriefing improves care and reduces error. To be effective, debriefs should be facilitated by trained individuals utilising structured and validated tools. Currently, in UK ambulance services there is no published evidence that structured processes utilising validated tools are being consistently delivered by trained facilitators, potentially impacting clinical practice.

Methods:

A pre-intervention survey related to debriefing was sent to 1000 clinicians within a specific geographical area of the trust via e-mail. In addition, 12 senior or advanced paramedics were recruited from the same area to participate in a training day and 12-week trial, utilising the Debrief Diamond as part of post-event debriefing. Following the trial period, all facilitators and participants of any recorded debriefs were invited to complete a post-intervention survey.

Results:

A total of 130 staff responded to the pre-intervention survey, with 22% reporting that previous debriefs had not identified areas for learning, and 13% reporting that previous debriefs had not identified good practice, learning opportunities or near misses. Post-intervention, 89% believed the process of debriefing was improved utilising a structured framework, 85% stated trained individuals improved the process, 93% reported the identification of good practice, 70% identified team level learning and 100% of facilitators reported improvements in identifying and supporting learning.

Conclusion:

Improvements in identifying good practice and learning opportunities were reported by both clinicians and facilitators in this evaluation, reflecting current evidence that structured and facilitated debriefs support safer care through the identification and subsequent reduction of human error. Consequently, the evaluation of appropriate debrief frameworks to provide consistency and validity to clinical debriefs in the pre-hospital environment should be considered to support safer clinical care.

The use of psychiatry-focused simulation in undergraduate nursing education: A systematic search and review

Evidence on the use of simulation to teach psychiatry and mental health (including addiction) content is emerging, yet no summary of the implementation processes or associated outcomes exists. The aim of this study was to systematically search and review empirical literature on the use of psychiatry-focused simulation in undergraduate nursing education. Objectives were to (i) assess the methodological quality of existing evidence on the use of simulation to teach mental health content to undergraduate nursing students, (ii) describe the operationalization of the simulations, and (iii) summarize the associated quantitative and qualitative outcomes. We conducted online database (MEDLINE, Embase, ERIC, CINAHL, PsycINFO from January 2004 to October 2015) and grey literature searches. Thirty-two simulation studies were identified describing and evaluating six types of simulations (standardized patients, audio simulations, high-fidelity simulators, virtual world, multimodal, and tabletop). Overall, 2724 participants were included in the studies. Studies reflected a limited number of intervention designs, and outcomes were evaluated with qualitative and quantitative methods incorporating a variety of tools. Results indicated that simulation was effective in reducing student anxiety and improving their knowledge, empathy, communication, and confidence. The summarized qualitative findings all supported the benefit of simulation; however, more research is needed to assess the comparative effectiveness of the types of simulations. Recommendations from the findings include the development of guidelines for educators to deliver each simulation component (briefing, active simulation, debriefing). Finally, consensus around appropriate training of facilitators is needed, as is consistent and agreed upon simulation terminology.

Peer-assisted debriefing of multisource feedback: an exploratory qualitative study

BACKGROUND

The Manitoba Physician Achievement Review (MPAR) is a 360-degree feedback assessment that physicians undergo every 7 years to retain licensure. Deliberate reflection on feedback has been demonstrated to encourage practice change. The MPAR Reflection Exercise (RE), a peer-assisted debriefing tool, was developed whereby the physician selects a peer with whom to review and reflect on feedback, committing to change. This qualitative study explores how physicians who had undergone the MPAR used the RE, what areas of change are identified and committed to, and what they perceived as the role of reflection in the MPAR process.

METHODS

The MPAR RE was piloted out to a cohort of MPAR-reviewed physicians. Thematic analysis was conducted on completed exercises (n = 61). Semi-structured interviews were conducted with individuals (n = 6) who completed the MPAR RE until saturation was reached.

RESULTS

Physicians reviewed feedback with a range of peers, including colleagues, staff, and spouses. Many physicians were surprised by feedback, both positive and negative, but interviewees found the RE useful in processing feedback. Areas where physicians committed to change were diverse, covering all CanMEDS roles. Most physicians identified themselves as being successful in implementing change, though time, habit, and structures were cited as barriers.

CONCLUSIONS

Peer-assisted debriefing can assist reflection of multisource feedback. It is easy to implement, is not resource-intensive, and feedback implies that it is effective at promoting change. Participants, with the aid of peers, identified areas for change, developed approaches for change, and largely thought themselves successful at implementing changes. Areas of change included all seven CanMEDS roles.

Exploring the use of high-fidelity simulation training to enhance clinical skills

The use of interprofessional simulation training to enhance nursing students' performance of technical and non-technical clinical skills is becoming increasingly common. Simulation training can involve the use of role play, virtual reality or patient simulator manikins to replicate clinical scenarios and assess the nursing student's ability to, for example, undertake clinical observations or work as part of a team. Simulation training enables nursing students to practise clinical skills in a safe environment. Effective simulation training requires extensive preparation, and debriefing is necessary following a simulated training session to review any positive or negative aspects of the learning experience. This article discusses a high-fidelity simulated training session that was used to assess a group of third-year nursing students and foundation level 1 medical students. This involved the use of a patient simulator manikin in a scenario that required the collaborative management of a deteriorating patient.

A Randomized Trial of SMART Goal Enhanced Debriefing after Simulation to Promote Educational Actions

Introduction

Goal setting is used in education to promote learning and performance. Debriefing after clinical scenario-based simulation is a well-established practice that provides learners a defined structure to review and improve performance. Our objective was to integrate formal learning goal generation, using the SMART framework (Specific, Measurable, Attainable, Realistic, and Time-bound), into standard debriefing processes (i.e., “SMART Goal Enhanced Debriefing”) and subsequently measure the impact on the development of learning goals and execution of educational actions.

Methods

This was a prospective multicenter randomized controlled study of 80 emergency medicine residents at three academic hospitals comparing the effectiveness of SMART Goal Enhanced Debriefing to a standard debriefing. Residents were block randomized on a rolling basis following a simulation case. SMART Goal Enhanced Debriefing included five minutes of formal instruction on the development of SMART learning goals during the summary/application phase of the debrief. Outcome measures included the number of recalled learning goals, self-reported executed educational actions, and quality of each learning goal and educational action after a two-week follow-up period.

Results

The mean number of reported learning goals was similar in the standard debriefing group (mean 2.05 goals, SD 1.13, n=37 residents), and in the SMART Goal Enhanced Debriefing group (mean 1.93, SD 0.96, n=43), with no difference in learning goal quality. Residents receiving SMART Goal Enhanced Debriefing completed more educational actions on average (Control group actions completed 0.97 (SD 0.87), SMART debrief group 1.44 (SD 1.03) p=0.03).

Conclusion

The number and quality of learning goals reported by residents was not improved as a result of SMART Goal Enhanced Debriefing. Residents did, however, execute more educational actions, which is consistent with the overarching intent of any educational intervention.

Intensive care nursing students' perceptions of simulation for learning confirming communication skills: A descriptive qualitative study

AIM

The aim of this study was to explore intensive care nursing students experiences with confirming communication skills training in a simulation-based environment.

RESEARCH METHODOLOGY

The study has a qualitative, exploratory and descriptive design. The participants were students in a post-graduate program in intensive care nursing, that had attended a one day confirming communication course. Three focus group interviews lasting between 60 and 80min were conducted with 14 participants. The interviews were transcribed verbatim. Thematic analysis was performed, using Braun & Clark's seven steps.

FINDINGS

The analysis resulted in three main themes: "awareness", "ice-breaker" and "challenging learning environment". The participants felt that it was a challenge to see themselves on the video-recordings afterwards, however receiving feedback resulted in better self-confidence in mastering complex communication.

CONCLUSION

The main finding of the study is that the students reported improved communication skills after the confirming communication course. However; it is uncertain how these skills can be transferred to clinical practice improving patient outcomes.

Structured debriefing: What difference does it make?

Debriefing in simulation is a cornerstone of learning. However, in-depth studies examining simulation debriefing are scarce. This study explored four key debriefing attributes-feedback, reflection, knowledge development, and psychological safety-prior and subsequent to the implementation of a new pedagogical intervention in a pre-clinical scenario simulation course. The scenarios focused on patients with deteriorating conditions and took place at bachelor's nursing degree level. The new intervention for the debriefing sessions contained a detailed observation tool describing specific, correct nursing actions for deteriorating patients; video playback watched only by students acting as nurses, and debriefing organized into two sections. The study design was explorative. To generate data, 12 debriefing sessions were audio and video recorded in 2013 and 11 in 2014. Two student groups participated each year, comprising 16 and 10 students, respectively. Qualitative analysis was performed to examine the transcribed audio and video recordings. Relative to the 2013 cohort, the reflections of observers and the students acting as nurses were more assertive, and students' feedback was more specific and comprehensive in the 2014 cohort. Conducting in-depth studies examining debriefing is important to increase knowledge regarding the impact of pedagogical underpinnings on debriefing content and processes.

A Review of Debriefing Practices

Abstract. There appears to be a wide acceptance that debriefing plays an important role in the learning process of simulation-based programs. Indeed, the past decade has witnessed an increasing number of studies into debriefing across disciplines. Our research team has been conducting field research with airlines, over a number of years, to clarify what constitutes effective debriefing for airline pilot training. To assist this clarification, a comprehensive systematic review of existing studies into debriefing across disciplines was designed to direct further analysis of the data the team had collected. A preliminary investigation into this broad debriefing literature exposed that there was little consensus among many papers about effective debriefing practice owing to inconsistencies in: (a) methodological approaches, (b) terminology, and (c) professional focus. As a way of overcoming these inconsistencies, this paper initially synthesized research findings from a small number of existing systematic reviews scrutinizing debriefing across a variety of professional disciplines. The literature search identified 10 papers, three meta-analyses, and seven qualitative systematic reviews. This paper aims to identify key elements influencing learning outcomes from debriefing practices and presents the findings of this study as a single framework of debriefing elements.

Cognitive control level of action for analyzing verbal reports in educative clinical simulation situations

BACKGROUND

Several methods and theoretical frameworks have been proposed for efficient debriefing after clinical simulation sessions. In these studies, however, the cognitive processes underlying the debriefing stage are not directly addressed. Cognitive control constitutes a conceptual link between behavior and reflection on behavior to apprehend debriefing cognitively.

OBJECTIVES

Our goal was to analyze cognitive control from verbal reports using the Skill-Rule-Knowledge model. This model considers different cognitive control levels from skill-based to rule-based and knowledge-based control.

DESIGN

An experiment was conducted with teams of nursing students who were confronted with emergency scenarios during high-fidelity simulation sessions.

SETTINGS

Participants' descriptions of their actions were asked in the course of the simulation scenarios or during the debriefing stage.

PARTICIPANTS

52 nursing students working in 26 pairs participated in this study.

METHODS

Participants were divided into two groups: an "in situ" group in which they had to describe their actions at different moments of a deteriorating patient scenario, and a "debriefing" group, in which, at the same moments, they had to describe their actions displayed on a video recording. In addition to a cognitive analysis, the teams' clinical performance was measured.

RESULTS

The cognitive control level in the debriefing group was generally higher than in the in situ group. Good team performance was associated with a high level of cognitive control after a patient's significant state deterioration.

CONCLUSIONS

These findings are in conformity with the "Skill-Rule-Knowledge" model. The debriefing stage allows a deeper reflection on action compared with the in situ condition. If an abnormal event occurs as an adverse event, then participants' mental processes tend to migrate towards knowledge-based control. This migration particularly concerns students with the best clinical performance. Thus, this cognitive framework can help to strengthen the analysis of verbal reports.

A collaborative clinical simulation model for the development of competencies by medical students

Herein, we present a new collaborative clinical simulation (CCS) model for the development of medical competencies by medical students. The model is a comprehensive compendium of published considerations and recommendations on clinical simulation (CS) and computer-supported collaborative learning (CSCL). Currently, there are no educational models combining CS and CSCL. The CCS model was designed for the acquisition and assessment of clinical competencies; working collaboratively and supported by technology, small groups of medical students independently design and perform simulated cases. The model includes four phases in which the learning objectives, short case scenarios, materials, indices, and the clinical simulation are designed, monitored, rated and debriefed.

Debriefing and Feedback in the Current Healthcare Environment

Over the past several decades, simulation-based learning and postsimulation debriefing have become a mainstay of clinical education in healthcare. With origins in both the military and aviation industries, debriefing in particular has been used across multiple nursing and medicine disciplines to promote team training and reflective learning. Self-reflection and improvement in practice are at the core of effective debriefing. Feedback and simulation experts have continued to develop more effective debriefing strategies. Several models are described in the literature, and healthcare educators now have a variety of resources at their disposal. Many of these debriefing techniques offer thoughtful guidance for providing constructive, real-time clinical feedback to students. Incorporating reflective feedback strategies in clinical learning promotes meaningful learning. This, in turn, will only strengthen the capabilities of students and better prepare them for the complexities they will face in clinical practice.

Nursing students' perceptions of learning after high fidelity simulation: Effects of a Three-step Post-simulation Reflection Model

BACKGROUND

High-fidelity simulation (HFS) has become a bridge between theoretical knowledge and practical skills. A safe and realistic environment is commonly used in nursing education to improve cognitive, affective and psychomotor abilities. Debriefing following a simulation experience provides opportunities for students to analyze and begin to reflect upon their decisions, actions and results. The nursing literature highlights the need to promote the concept of reflective practice and to assist students in reflection, and research indicates the need to refine and develop debriefing strategies, which is the focus of the current paper.

PURPOSE

To explore the value of reflections after HFS by investigating nursing students' perceptions of their learning when a Three-step Post-simulation Reflection Model is used.

DESIGN

A qualitative descriptive research approach was applied.

METHOD

A Three-step Post-simulation Reflection Model that combined written and verbal reflections was used after an HFS experience in a second-year course in the Bachelor Program in Nursing at Luleå University of Technology, Sweden. Reflective texts written before and after a verbal group reflection were subjected to qualitative content analysis.

FINDINGS

The main theme in the first written reflections was identified as "Starting to act as a nurse", with the following categories: feeling stressed, inadequate and inexperienced; developing an awareness of the importance of never compromising patient safety; planning the work and prioritizing; and beginning to understand and implement nursing knowledge. The main theme in the second written reflections was identified to be "Maturing in the profession", with the following categories: appreciating colleagues, good communication and thoughtfulness; gaining increased self-awareness and confidence; and beginning to understand the profession.

CONCLUSION

The Three-step Post-simulation Reflection Model fostered an appreciation of clear and effective communication. Having time for thoughtfulness and reflection promotes self-awareness and a better understanding of both the nursing profession and patient safety. The progress demonstrated in the depth of the themes in the written reflections indicates that repeated reflections stimulate and enhance student learning. The findings point towards the potential effectiveness of alternate methods of reflections.

"Clinical simulation as a learning tool in undergraduate nursing: Validation of a questionnaire"

BACKGROUND

Clinical simulation allows both students and professionals to perform their clinical practice in a safe environment, facilitating the standardization of contents and promoting the integration of theoretical knowledge into the clinical practice.

OBJECTIVES

To design and validate in Spanish the Satisfaction Scale Questionnaire with High-Fidelity Clinical Simulation, instrument created to assess the nursing students' satisfaction with the use of clinical simulation in training.

METHODS

The scale items were developed from a review of the literature. Content validity was established by an expert panel. This questionnaire was validated by 150 nursing students in the second year of the Bachelor Degree in Nursing at a Spanish university during the academic year 2013/2015. Lawshe formula was used to determine its validity, while for the construct validity a factor analysis was conducted using the principal component and Varimax rotation. Cronbach Alpha was used to determine internal consistency.

RESULTS

The questionnaire developed presents satisfactory internal consistency (alpha 0.857). The factorial analysis indicated a structure of eight principal components that explain the 62.85% of the total variance explained, and in turn each subscale presented acceptable internal consistency. Frequency analysis results show a satisfaction degree higher than 80%, emphasizing "the realism of the cases" (98.7%), that "many benefits are obtained as clinical simulation relates theory to practice" (98.7%), "priorities are established "(97.4%)," errors are corrected after debriefing" (93.4%), and "communication and teamwork improved" (90%).

CONCLUSIONS

The scale designed and validated on high-fidelity clinical simulation in the Spanish population is satisfactory and adequate. Nursing students at the University of Cantabria (Spain) reported a high satisfaction degree with clinical simulation, confirming its usefulness in the teaching–learning process.

Debriefing in pediatrics

Debriefing is a conversational session that revolves around the sharing and examining of information after a specific event has taken place. Debriefing may follow a simulated or actual experience and provides a forum for the learners to reflect on the experience and learn from their mistakes. Originating from the military and aviation industry, it is used on a daily basis to reflect and improve the performance in other high-risk industries. Expert debriefers may facilitate the reflection by asking open-ended questions to probe into the framework of the learners and apply lessons learned to future situations. Debriefing has been proven to improve clinical outcomes such as the return of spontaneous circulation after cardiac arrest and the teaching of teamwork and communication in pediatrics. Incorporating debriefing into clinical practice would facilitate the cultural change necessary to talk more openly about team performance and learn from near misses, errors, and successes that will improve not only clinical outcome but also patient safety.