1. health and fitness
2. exercise

SIMULATION DEBRIEFING: TOOLS TO GUIDE BEST PRACTICE
FOR NURSING FACULTY
A Project Presented to the Faculty
of
California State University, Stanislaus
In Partial Fulfillment
of the Requirements for the Degree
of Master of Science in Nursing
By
Wendy Matthew
May 2015
CERTIFICATION OF APPROVAL
SIMULATION DEBRIEFING: TOOLS TO GUIDE BEST PRACTICE
FOR NURSING FACULTY
by
Wendy Matthew
Signed Certification of Approval Page is on file with the University Library
Dr. Marla Seacrist, RN, PhD
Associate Professor of Nursing
Date
Jean Ann Britt, RN, PhDc
Assistant Professor of Nursing
Date
Marie Gilbert, DNP(c), RN, CHSE
Simulation Coordinator
Date
© 2015
Wendy Matthew
ALL RIGHTS RESERVED
DEDICATION
I dedicate this project to my amazing family. My husband Craig, the hardest
working person I know, yet always willing to take on extra when I fall behind. I am
blessed to have you as my partner in life. My daughter Baylee, the inspiration for
everything I do. May you always have a passion for learning. BJ and Dorea, the best
sisters anyone could ask for. Without the two of you, I would have lost my mind
years ago. To Granny, always there when I need you. You all mean the world to me!
“Unless someone like you cares a whole awful lot, nothing is going to get
better. It’s not.”- Dr. Seuss
iv
ACKNOWLEDGEMENTS
I would like to recognize my chair, committee members, faculty, and friends.
My Chair, Dr. Marla Seacrist, for always being available….even on the weekends.
Your knowledge, patience, and guidance made this project possible. My committee
member, Jean Ann Britt, for your flexibility, encouragement, and time spent proof
reading these chapters. My committee member, Marie Gilbert, for sharing your
expertise in simulation and debriefing. The content of this project was definitely
enriched by your recommendations. Dr. Debra Tavernier, for your love of simulation
and continued confidence in my abilities to reach our goals. Dr. Carolyn Martin for
your suggestion to start this project early and all your assistance along the way. My
fellow classmates, Cohort 3, I have learned so much from each and every one of you.
Jennifer Serratos, my friend and classmate, for all the times I laughed until I cried,
you truly made this journey more enjoyable.
v
TABLE OF CONTENTS
PAGE
Dedication ...............................................................................................................
iv
Acknowledgements .................................................................................................
v
Abstract ...................................................................................................................
vii
Introduction .............................................................................................................
1
Theory .........................................................................................................
Checklist .....................................................................................................
Purpose........................................................................................................
2
3
4
Literature Review....................................................................................................
5
Prebrief ........................................................................................................
Simulation ...................................................................................................
Debrief ........................................................................................................
Debrief Methods .........................................................................................
Debrief Tools ..............................................................................................
Consensus ...................................................................................................
5
7
8
10
14
16
Learning Theory......................................................................................................
19
Social Learning Theory...............................................................................
Experiential Learning Theory .....................................................................
Theory as a Guide .......................................................................................
19
24
26
Debriefing Tool .......................................................................................................
28
Debrief Facilitator .......................................................................................
Checklists ....................................................................................................
Tool Creation ..............................................................................................
28
29
31
Evaluation ...............................................................................................................
42
Facilitator ....................................................................................................
Participant ...................................................................................................
Summary .....................................................................................................
42
43
44
References ...............................................................................................................
46
vi
Appendices
A.
B.
C.
D.
E.
Bandura’s Phases of Learning ....................................................................
Kolb’s Cycle of Learning............................................................................
Debrief Tool for Nurse Faculty...................................................................
Debrief Tool: Faculty Evaluation ...............................................................
Participant Evaluation .................................................................................
vii
55
56
57
58
59
ABSTRACT
The purpose of this project is to develop a simulation debriefing tool to guide best
practice for nursing faculty. Although research has shown that the debriefing process
is a critical element of the simulation experience, practices vary greatly. Simulation is
increasingly being utilized in nursing education and provides an opportunity for
nursing students to gain clinical experience in a safe environment. Debriefing takes
place immediately after the simulation and sets the stage for learning to occur. The
greatest gains in learning happen when the facilitator is knowledgeable about the
process and follows evidence based guidelines. A checklist for best practice is
essential to ensure that important debriefing aspects are not overlooked and that
evidence based practices are adhered to. Bandura’s social learning theory and Kolb’s
experiential learning theory were the theoretical framework’s used for this project. At
the conclusion of this project, best practices were identified and a debriefing checklist
was developed for use by nursing faculty. The debrief tool will be evaluated by
faculty and simulation participants to identify effectiveness and potential gaps. In
conclusion, the debrief checklist provides an evidence based standardized approach to
debriefing which increases practicality, compliance, consistency, and positive
learning outcomes. There is a great need to standardize the debriefing process and
implications for future nursing research should focus on implementation and
evaluation of this tool, as well as others.
viii
INTRODUCTION
Simulation is an active learning strategy that engages learners and provides
immediate feedback and reinforcement of learning (Jeffries, 2005). These events
imitate the clinical environment (Dreifuerst, 2010) and involve caring for a patient
who is represented by a human patient simulator (HPS) or a standardized patient
(Cato, 2012). Participants in simulations are able to develop critical nursing skills
while caring for patients in a safe environment (Hayden, Smiley, Alexander,
Kardong-Edgren, & Jeffries, 2014). The use of simulation has become widely
accepted as a valuable teaching strategy (Cato, 2012) and is increasingly being
utilized in nursing education (Dufrene & Young, 2014; Hayden et al., 2014; Neill &
Wotton, 2011). Learning in simulation occurs through an integration of both the
simulation experience and a reflection of the event during debriefing (Decker et al.,
2013). The greatest gains in knowledge are not seen following the simulation event,
but rather after the debriefing session has occured (Shinnick, Woo, Horwich, &
Steadman, 2011). Debriefing allows nursing students to engage in guided reflection
which improves knowledge and skills (Neill & Wotton, 2011). As simulation
education increases in nursing education, a need exists to improve and understand
debriefing strategies (Dreifuerst, 2010; Neil & Wotton, 2011). Increasing debriefing
knowledge will allow nursing faculty to conduct debriefing sessions using practices
known to improve learning outcomes (Neill & Wotton, 2011).
1
2
Debriefing in simulation has been identified as a crucial element to learning
(Chronister & Brown, 2012; Decker et al., 2013; Fanning & Gaba, 2007; Mariani,
Cantrell, Meakim, Prieto & Dreifuerst, 2013; Neill & Wotton, 2011; Parker &
Myrick, 2010) yet practices continue to vary greatly (Levitt-Jones & Lapkin 2014).
The literature supports a need for identification of best practices and standardization
in the debriefing process (Fanning & Gaba, 2007; Neill & Wotton, 2011). Best
practices in simulation debriefing will be identified for the purpose of developing a
debrief checklist to guide nursing faculty in the debriefing process.
Theory
In order to provide a theoretical foundation for this culminating experience,
several theories were examined for their potential contribution to this project.
Learning theories address how people learn by describing, explaining, or predicting
the learning process (Braungart & Braungart, 2008). It is important to comprehend
learning theories in order to gain a better understanding of the learner, and the manner
of learning that occurs in simulation and debriefing. Educators can create positive
learning environments and develop educational strategies based upon learning theory
principles. Bandura’s (1977) social learning theory and Kolb’s (1984) experiential
learning theory will be the foundational philosophies used to guide this work.
Bandura’s (1977) social learning theory describes learning as a process which
includes attention, retention, reproduction including feedback, and motivation (p. 2329). These four phases are seen during the simulation event and the debriefing
process. The simulation environment allows the learner to observe the actions of
3
educators and peers (attention and retention), to participate in patient scenarios
(reproduction), to discuss the scenario (feedback), and to reflect upon the actions
taken during the experience (motivation).
Kolb’s (1984) experiential learning theory emphasizes experience and
reflection as playing central roles in the learning process (p. 40). This learning theory
is applicable to debriefing in simulation as simulation is the experience, and
debriefing is the reflection. The four stages of learning include a concrete experience,
a reflective observation, an abstract conceptualization, and an active experimentation
(Kolb, 1984, p. 30). This process of learning is seen as participants engage in a
simulation event, discuss and reflect upon the event in debriefing, form new ideas and
learn new concepts, and then move forward to apply this knowledge in a new
experience. Concepts from both the social learning theory (Bandura, 1977) and the
experiential learning theory (Kolb, 1984) will be evident throughout this project.
Checklist
The checklist has proven to be an exceptional tool for guiding best practice.
Kohn, Corrigan, and Donaldson (2000), report that standardization and the use of
checklists are methods used to reduce errors. An error has been defined as “the
failure of a planned action to be completed as intended (error of execution), or the use
of a wrong plan to achieve an aim (error of planning)” (Kohn et al., 2000, p.54). To
decrease the likelihood of an error occurring, memory should not be relied upon and
the process should be made as simple as possible. According to Gawande (2009),
checklists provide a higher standard of performance. They can provide protection
4
against the unreliability of human memory and attention. Checklists can ensure that
steps are not missed, even those remembered, but intentionally skipped because of
perceived unimportance (Gawande, 2009). A debriefing checklist can be utilized by
nursing faculty as a guide for best practice.
Purpose
The ultimate goal of simulation debriefing is for student learning to occur.
The debriefing process is essential to that goal. With debriefing being such an
important aspect of student learning, there needs to be a standardized method and
guide for best practices for nursing faculty. The purpose of this project is to develop
a debrief checklist to guide nursing faculty in the debriefing process utilizing best
practice. This goal will be accomplished by conducting a review of the literature for
simulation debriefing methods, identifying best practices in debriefing, applying
foundational learning theories, and lastly, combining this knowledge to develop the
debriefing tool. This tool will standardize debriefing techniques, ensure best practices
are being used, improve student learning outcomes, and ultimately, produce better
nurses.
LITERATURE REVIEW
Consideration should be given to three major areas of the simulation
experience when identifying best practices for debriefing in simulation. Those areas
include the pre-brief, the simulated event, and the debriefing (Arafeh, Hansen, &
Nichols, 2010). All parts of the simulation experience are important to learning
outcomes as they are interrelated and can impact other areas. According to Franklin et
al. (2013), expected outcomes will be achieved in simulation when there is
preparation before, facilitation during, and debriefing after the simulated event.
Research has established that debriefing is where the majority of learning occurs
(Mariani, Cantrell, Meakim, Prieto & Dreifuerst, 2013; Shinnick, Woo, Horwich, &
Steadman, 2011), therefore it is important to identify best practices. Best practices for
debriefing in simulation will be the focus of this literature review in order to develop
a debrief checklist for nursing faculty.
Pre-brief
The pre-brief session takes place prior to the simulation. It is essential to
create a foundation for learning during the pre-brief (Wickers, 2010). Several key
concepts should be discussed with learners during this time including the purpose of
the simulation, learning objectives, the debrief process, confidentiality, and basic
ground rules (Arafeh et al., 2010; Fanning & Gaba, 2007; Franklin et al., 2013;
Zigmont, Kappus, & Sudikoff, 2011). Students should be oriented to the environment,
the equipment, and the human patient simulator (Franklin et al, 2013; Wickers, 2010).
5
6
According to Wickers (2010), establishing trust is imperative at this point. This
period of time is essential for setting the tone of the simulation and developing trust
between the facilitator and the student (Wickers, 2010) and should be established
early on, ideally in the pre brief session (Fanning & Gaba, 2007). The facilitator will
need to impress upon the students the importance of confidentiality and that anything
that is discussed or done during the simulation must stay within the group (Arafeh et
al., 2010; Wickers, 2010). Learners should be given background information of the
scenario, an explanation of roles, and time to develop a plan prior to the start of the
scenario (Franklin et al., 2013). Key concepts are covered in the pre-brief session
which will set the stage for the remainder of the simulation.
Creating an environment that will promote learning during the pre-brief
session, is also an essential aspect to a successful debriefing. To actively involve
students, the facilitator must create an environment in which student participation can
flourish (Wickers, 2010; Zigmont et al., 2011). Consideration should be made to the
space of the environment. According to Decker and Dreifuerst (2012), a round table
works well with small groups and establishes equality among the participants.
Overcrowding in a room, or a room that is too large, will create barriers to open
communication (Wickers, 2010). The environment should resemble that of a clinical
setting including student clothing. Students should dress in the attire required of them
in their clinical sites which will enhance fidelity and promote professional behaviors
(Wickers, 2010). Attention should be given to environmental factors in the pre-
7
briefing session and throughout the simulation. Following the pre-brief session is the
simulation.
Simulation
Simulation events are activities that imitate the clinical environment
(Dreifuerst, 2010; Jeffries, 2005). The simulation environment, with patient scenarios
allow students to participate in caring for patients in a safe environment while
developing critical nursing skills (Hayden Smiley, Alexander, Kardong-Edgren, &
Jeffries, 2014). These events require active student participation, promoting
successful learning through engagement, discussion, observation, and reflection
(Rothgeb, 2008). The use of simulation in nursing education creates an atmosphere
that allows experiential learning to occur (Norman, 2012). Consideration should be
given to learning objectives, pre-existing knowledge, experience level, learner needs,
and expected outcomes (Arafeh et al., 2010; Decker et al., 2013; Franklin et al., 2013,
Jeffries, 2005). The facilitator role is crucial during the simulation as they are
responsible for ensuring objectives are being met and are able to recognize when cues
are needed to guide student teaching (Franklin et al., 2013). According to Garret,
MacPhee, & Jackson (2010), faculty must be aware of the need for prompts, and cues
should be imbedded into the patient history and throughout the scenario to guide
student learning. A debriefing session should follow all simulations with a focus on
reflective learning (Decker et al., 2013).
8
Debrief
The debriefing process is described as a reflective conversation, amongst the
facilitator and the learners, examining the clinical simulation experience (Arafeh et
al., 2010; Cant & Cooper, 2011; Decker et al., 2013; Dreifuerst, 2009; Fanning &
Gaba, 2007). The debriefing process promotes understanding and supports the
transfer of knowledge, skill, and attitude (Decker et al., 2013) while fostering clinical
reasoning and judgment skills through reflective learning processes (Arafeh et al.,
2010; Dreifuerst, 2009). In the debriefing process, students learn the most amount of
knowledge during a simulation and are able to change their thinking to better handle
future situations with similar circumstances (Mariani et al., 2013; Rudolph, Simon,
Dufresne, & Raemer, 2006). Guidance by nurse faculty is critical during the
debriefing process to promote learning. A debrief tool will assist nurse faculty with
the debriefing process and ensure that the essential elements to foster learning are
present in the debriefing session.
“The primary intention of debriefing is to reinforce learning objectives and
critique performance in an objective, nonjudgmental atmosphere for the purpose of
learning” (Chronister & Brown, 2012, e281). Shinnick et al. (2011), identify the
debriefing component of simulation as the most valuable in producing gains in
knowledge. During the debriefing portion of simulation, the student engages in
reflective thinking of the simulated event guided by the debrief facilitator. The focus
remains on the learning outcomes of the simulation to guide teaching of best clinical
nursing practice (Chronister & Brown, 2012).
9
The debriefing session must be facilitated by a person competent in the
debriefing process (Cant & Cooper, 2011; Decker et al., 2013; Dreifuerst, 2010), with
an understanding of best practices to facilitate student learning (Dreifuerst, 2009).
The educational outcomes are dependent upon the ability of the facilitator to offer
feedback in accordance with best practice (Cant & Cooper, 2011) and then link that
information to the real world (Middleton, 2012). The skills of the debrief facilitator
are important to ensure that the best possible learning will occur (Decker et al., 2013;
Overstreet, 2008). Formative feedback is an important element to experiential
learning which can be provided through structured facilitated debriefing (Cant &
Cooper, 2011). The ability to analyze, understand, and assimilate learning
experiences may be difficult for some learners (Fanning & Gaba, 2007), which
highlights the importance of the facilitator role. A debriefing tool will assist nurse
faculty with incorporating the important components that will help these learners
make the connection between theory and practice.
Research has shown that the debriefing process is an important element of the
simulation experience (Chronister & Brown, 2012; Decker et al., 2013; Dufrene &
Young, 2014; Fanning & Gaba, 2007; Mariani et al., 2013; Neill & Wotton, 2011;
Parker & Myrick, 2010). The use of simulation is increasingly being utilized in
current nursing education (Dreifuerst, 2009; Middleton, 2012; Neill & Wotton, 2011;
Overstreet, 2008); therefore it is important to understand the concepts and processes
of best practice in simulation debriefing.
10
Debrief Methods
Debriefing has been identified as an essential element to simulation,
nevertheless practices vary greatly (Dreifuerst, 2009). Rudolph et al. (2006) provide a
method for debriefing called “debriefing with good judgment” (p. 49). The three
elements of this method include frames, genuine curiosity, and a conversational
technique. The frames are the learner’s knowledge, assumptions, and feelings which
drive their actions during a simulated event. By uncovering these frames, the
facilitator can reframe assumptions and feelings to improve future results. Genuine
curiosity leads to uncovering learner frames and approaching mistakes as puzzles to
be solved rather than as errors. Advocacy and inquiry is the conversational technique
used to illicit the judgment of the facilitator and the frames of the learner. It involves
discussing the facilitator’s objective observation and subjective judgment about the
learner actions followed by an inquiry into what led to those actions. This type of
reflective conversation reduces tension and helps to build trust between the facilitator
and the learner (Rudolph et al., 2006).
Cant and Cooper (2011) present a framework for debriefing based upon the
Advanced Life Support Group of the Resuscitation Council by Mackaway-Jones and
Walker. This framework presents 3 stages including set, dialogue, and closure. The
set stage focuses on preparation including facilitator education, environment, and
learner preparation. This stage should be timely, constructive, non-judgmental, and
based upon direct observation of the scenario. The dialogue stage focuses on the
actual debriefing session including event description, analysis, and application. This
11
stage is learner centered with a focus on positive performance and key points for
improvement. The closure stage focuses on the summary including final questions
and key learning points. The facilitator summarizes good performance, areas for
improvement, and key learning points (Cant & Cooper, 2011).
Dreifuerst (2009) identifies the attributes of debriefing in simulation as
reflection, emotion, reception, integration, and assimilation. Reflection is the
opportunity to examine the experience and discuss the thinking processes that took
place. Emotions can surface during simulation and it is important to identify and
discuss those emotions. Reception is the opportunity to offer and receive feedback.
This is the time to discuss strengths and weaknesses in a positive manner. Integration
requires the facilitator to scaffold the experience with learner knowledge. This usually
occurs through common nursing knowledge such as the nursing process. Assimilation
is the ultimate goal of simulation with the learner demonstrating successfully that
they can transfer what they have learned from the current situation to the next
situation (Dreifuerst, 2009).
Debriefing for Meaningful Learning (DML) is a model presented by
Dreifuerst (2010) which emphasizes the importance of reflection during debriefing.
Events of the simulation and student thoughts are guided by recollection, review,
reflection, and analysis. This model lists several elements of debriefing to promote
meaningful learning and achieve clinical reasoning. The debriefing process focuses
on guided reflection and is based upon six E’s which consist of engage, evaluate,
explore options, explain alternatives, elaborate on thinking, and extend to the next
12
clinical situation. Using reflection and the six E’s can guide debriefing and foster
meaningful learning (Dreifuerst, 2010).
The plus/delta (+/∆) method of debriefing is another technique used in
debriefing (Fanning & Gaba, 2007). This method focuses on the positive (+) events of
the simulation as well as the events that should be changed (∆). Two columns are
created and learners are asked to reflect on the simulation and place events in either
the (+) or the (∆) column. Through reflective discussion learners are able to identify
what went well, what could be improved upon, and what changes will be made in
future practice (Fanning & Gaba, 2007).
Zigmont, Kappus, and Sudikoff (2011), describe a 3D Model of Debriefing.
Defusing, Discovering, and Deepening are the 3D’s of the debriefing framework. The
defusing phase follows the pre briefing session and the simulation experience. This
phase investigates emotions experienced during the simulation. It is important for
participants to discuss their feelings so that they are able to move forward with
learning. The discovering phase involves examining thinking processes and
comparing those ideas to new information. The learners should engage in analogical
reasoning by making connections between past and present experiences. During the
deepening phase, the learner makes the connection between learning and practice.
Learners discuss how they would apply the information in actual practice. This phase
can be enhanced by repeating the simulation (Zigmont et al., 2011).
Middleton (2012) presents three phases of debriefing in simulation which
includes exploring ideas and facts, understanding, and summarizing. Exploring
13
reactions and discussing facts addresses the emotional state of the learners and
presents the facts. This phase helps to ensure that all participants are on the same
page. During the understanding phase thought processes are examined and concepts
are clarified. The summarizing phase includes identifying what went well, what
should be changed, and major take away messages (Middleton, 2012).
Chronister & Brown (2012) examined the video playback method of
debriefing. The traditional approach to debriefing was defined as a verbal discussion
lead by a debrief facilitator. Video assisted verbal debriefing may also be a useful
teaching tool because it adds visual reinforcement to the experience. The results of
this study indicate that video assisted debriefing engage students and positively affect
the quality and speed of student performance. However, the traditional verbal method
of debriefing has a higher impact on knowledge retention. Video should not replace
verbal debriefing time, but rather add to it which will increase the time needed to
debrief (Chronister & Brown, 2012). Wickers (2010) also supports the use of video
facilitated feedback by stating that it is a powerful tool in the reinforcement of
positive behaviors and initiates discussions about negative behaviors.
Cheng et al. (2013) examined the benefits of scripted vs. unscripted debriefing
in simulation. This study found that scripted debriefing sessions yield better
outcomes. Participants that received the scripted debriefing showed a greater
acquisition of knowledge and performance compared to the participants that received
the unscripted debriefings. Use of a script positively affects learning outcomes and
can help to standardize the delivery of debriefing sessions (Cheng et al., 2013).
14
Debrief Tools
Debriefing tools have also been developed to guide methods. The Center for
Medical Simulation (CMS) has created a debriefing assessment tool called the
Debriefing Assessment for Simulation in Healthcare (DASH) which is designed to
assist in evaluating and developing debriefing skills (CMS, 2013). The DASH
assesses the strategies and techniques used to conduct debriefings which are based on
evidence and theory about how people learn and change in experiential contexts. The
CMS developed DASH by identifying best practices through a literature review and
an expert panel. Several DASH tools are available for both the student and the debrief
facilitator (CMS, 2013).
The CMS (2013) identifies six elements of debriefing to guide best practice.
Element one is setting the stage for an engaging learning environment. This element
stresses the importance of a prebrief and that several key areas are covered including
learning objectives, ground rules, confidentiality, and comfortable environment.
Element two is maintaining an engaging context for learning. This element includes
clarifying debriefing goals, participant roles, expectations, respect, and fidelity.
Element three is structuring the debriefing in an organized way. All debriefings
should have a beginning, middle and end. The beginning phase investigates reactions
and emotions. The Middle phase analyzes simulation events and relevant issues. The
summary phase includes reviewing lessons learned and recommendations to improve
future practice. Element four is provoking interesting and engaging discussions that
foster reflective practice. The main goal is to facilitate guided reflection and have
15
participants analyze their own thoughts and actions. Element five is recognizing
performance gaps. This phase includes providing feedback and investigating the
thoughts, beliefs, and assumptions that may have contributed to their actions. Element
six includes closing the performance gap. This is accomplished through discussion
and teaching. Evaluation of simulation objectives and relation to curriculum are
reviewed (CMS, 2013).
Reed (2012) conducted research on the Debriefing Experience Scale to assess
student debriefing experiences. The scale was developed to measure the student
experience during debriefing as well as the importance of those experiences to the
student. This scale examines four content areas important for an effective debriefing
session. The first content area addressed is thoughts and feelings. Questions asked in
this area include analysis of thoughts, resolution of issues, and environmental
conditions. The second area addressed is learning and making connections. Questions
asked in this area relate to clarification, self-awareness, and making connections
between theory and clinical. The third area addressed is facilitator skill in conducting
the debriefing session. Questions asked in this section relate to time, reflection, and
content. The last area addressed is facilitator guidance. This area asked questions
about teaching, guidance, and constructive evaluation (Reed, 2012). This tool could
be useful in determining areas that the learners find important, and structuring
debriefing based upon some of those ideas. Several components will be incorporated
into the debriefing tool including addressing feelings, student self-awareness, analysis
of thoughts, and connecting theory with practice.
16
Consensus
There is not a general consensus in the literature regarding the exact process
for best practices in debriefing. However, the literature does provide many common
concepts that emerge as essential to an effective debriefing session. These concepts
emphasize the importance of preparing for the debriefing session and conducting the
debriefing. Preparation is as important as the debriefing session itself, therefore many
of the concepts focus on preparing before the debriefing occurs.
Several common concepts related to preparing for a debriefing emerged from
the literature including:
•
Thorough student orientation (Arafeh et al., 2010; Cant & Cooper, 2011; CMS,
2013; Fanning & Gaba, 2007; Franklin et al., 2013; Reed, 2012; Wickers, 2010;
Zigmont et al., 2011 );
•
General set up and preparation of the environment (Cant & Cooper, 2011; CMS,
2013; Decker & Dreifuerst, 2012; Wickers, 2010; Zigmont et al., 2011);
•
Confidentiality and building trust (Arafeh et al., 2010; CMS, 2013; Fanning &
Gaba, 2007; Rudolph et al., 2006; Wickers, 2010);
•
Length of time used to debrief (Cant & Cooper, 2011; Chronister & Brown, 2012;
Jeffries, 2005; Reed, 2012);
•
The importance of the debrief facilitator (Cant & Cooper, 2011; Chronister &
Brown, 2012; Decker et al., 2013; Dreifuerst, 2009; Dreifuerst, 2010; Franklin et
al., 2013; Overstreet, 2008; Reed, 2012);
17
•
Learning objectives used as guide (Cant & Cooper, 2011; Chronister & Brown,
2012; CMS, 2013; Franklin et al., 2013; Jeffries, 2005; Zigmont et al., 2011);
•
Expected outcomes (Cant & Cooper, 2011; CMS, 2013; Franklin et al., 2013;
Jeffries, 2005).
Several common concepts related to conducting the actual debriefing session
also emerged from the literature including:
•
Concepts of experiential learning (Dreifuerst, 2009; Norman, 2012; Rothgeb,
2008; Zigmont et al., 2011 );
•
Reflective learning (Arafeh et al., 2010; Cant & Cooper, 2011; CMS, 2013;
Decker et al., 2013; Dreifuerst, 2009; Dreifuerst, 2010; Fanning & Gaba, 2007;
Reed, 2012; Rothgeb, 2008; Rudolph et al., 2006; Zigmont et al., 2011);
•
Exploring emotions (Arafeh et al., 2010; CMS, 2013; Dreifuerst, 2009;
Middleton, 2012; Reed, 2012; Zigmont et al., 2011 );
•
Constructive feedback (Cant & Cooper, 2011; CMS, 2013; Dreifuerst, 2009;
Reed, 2012);
•
Video playback (Chronister & Brown, 2012; Wickers, 2010);
•
Linking theory with practice (CMS, 2013; Dreifuerst, 2009; Dreifuerst, 2010;
Middleton, 2012; Reed, 2012; Zigmont et al., 2011 ).
These common ideas can be combined and used for the development of a
checklist to guide best practice for nursing faculty during debriefings following a
simulation.
18
Debriefing in simulation is a complex concept which requires an examination
of best practices. It is a process that requires attention to all steps of the simulation
including the pre-brief, the simulation, and the debriefing. Although there is not a
clear consensus on the debriefing process, the importance of debriefing in simulation
was prevalent in the literature. With debriefing being such an important component to
learning, it is imperative to understand these concepts and to standardize the method
of conducting debriefing sessions.
LEARNING THEORY
Learning is defined as a change in the thinking process, emotional
functioning, and/or behaviors as a result of an experience (Braungart & Braungart,
2008). Simulation and debriefing can be viewed as an experience, but how learning
occurs in that experience is essential for educators to understand. Learning theories
provide a description and explanation of the learning process (Braungart & Braungart,
2008), which serves as a guide for educators in creating positive environments and
developing teaching strategies that match learner needs. Bandura’s social learning
theory (1977) and Kolb’s experiential learning theory (1984) will be discussed as they
provide valuable insight into the learning process that occurs during simulation and
debriefing. Concepts from these learning theories will be applied to the debriefing
tool.
Social Learning Theory
Bandura’s social learning theory (1977) is a cognitive learning theory which
can be utilized in the simulation and debriefing learning environments. According to
Braungart & Braungart (2008), social learning theory views learning as a social
process with role models providing examples of how to think, feel, and act.
Considerable learning occurs by observing the behaviors of others and noting the
effects of those actions (Braungart & Braungart, 2008). Bandura (1977) states that
people act and notice the effects that their actions have. People then develop an
assumption about which actions are most appropriate in which settings. These
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20
observations then serve as a guide for future actions. Outcomes change behavior due
to thought. No change will be seen if there is no learner awareness (Bandura, 1977).
During simulation and debriefing the learner participates in patient scenarios,
observes the actions of educators and peers, discusses the scenario, and reflects upon
the actions taken during the experience. The educator has a significant role in
ensuring that thinking occurs by investigating the thought processes that took place
during the simulation. Constructive feedback is essential so that the learner gains an
awareness of their mistakes and moves forward with an understanding of appropriate
actions.
According to Bandura (1997), an important personal characteristic of the
learner is self-efficacy, which involves the learner’s own beliefs about their abilities
to succeed. Self-efficacy beliefs determine the goals that learners will set for
themselves, how much effort they will expend, how long they will persist, and how
resilient they are in the face of failures and setbacks (Bandura, 1997). Previous
success and failures will impact learner self-efficacy. Learner confidence is very
important to successful learning (Braungart & Braungart, 2008). The educator can
increase self-efficacy and promote success by creating a positive learning
environment. For example, the educator should orient learners to any equipment that
will be used during the scenario so learners are prepared and confident in their ability
to be successful. Braungart and Braungart (2008) indicate the learning environment
should offer role models to demonstrate appropriate behaviors. The educator needs to
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ensure that the environment is safe and offer opportunities for demonstration,
reflection, and practice (Braungart & Braungart, 2008).
Social learning theory has four phases of learning that take place within the
learner (see Appendix A). Bandura (1977) describes these processes of learning as
the attentional processes, retention processes, motor reproduction processes, and
motivational processes. The attentional phase requires learner attention and
observation of a role model. This phase can be influenced by peers, whether or not
the learner finds the content valuable, or whether the content is engaging for the
learner. The second phase is the retention phase which involves storage and retrieval
of the information obtained. The learner cannot be affected if they cannot remember.
This phase can be influenced by repeated exposure, mental rehearsal, and actual
performance. The third phase is the reproduction phase which focuses on learner
performance guided by memory of observed actions. Feedback is important during
this phase as skills are not perfected by observation alone, nor by experience alone,
but rather an incorporation of both, guided by feedback. The last phase is the
motivational phase which focuses on learner motivation to perform the observed
behavior. Learners are more likely to demonstrate behaviors that are valued. The best
approach for educators during this phase is to demonstrate desired response, instruct
on how to do it, prompt when failure occurs, and reward when success is achieved
(Bandura, 1977).
The four phases of social learning can be seen in the learning processes that
occur within simulation and debriefing. During the attentional phase, observation and
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attention are required (Bandura, 1977; Braungart & Braungart, 2008). The simulation
and debriefing lab offers an environment that allows the learner to participate in
scenarios, to witness educator demonstrations, and to observe peer performance in
patient care. The focus of the scenario is on learning objectives related to patient
status, nurse interventions, and patient outcomes. Observation allows the student to
witness nurse actions, to think about patient interventions, and to pay attention to
appropriate actions that bring about best patient outcomes. Attention and observation
leads the learner to make a decision on the importance of the event and what
information they will take away from the experience (Bandura, 1977; Braungart &
Braungart, 2008).
During the retention phase, memory and retrieval of information are necessary
(Bandura, 1977; Braungart & Braungart, 2008). The learner must make sense of the
events and relate it to their own world (Fanning & Gaba, 2007). Real life patient
scenarios, similar to what students are seeing in the hospital, should be perceived as
important to the student and committed to memory. The more realistic the scenario is,
the easier it will be for learners to make the connection between theory, simulation,
and practice (Rothgeb, 2008). When learners perceive the information as important or
emotionally moving, they are more likely to retain it (Fanning & Gaba, 2007).
The reproduction phase focuses on learner performance of observed actions
(Bandura, 1977; Braungart & Braungart, 2008). This phase can be affected by
personal characteristics such as experience and expectations. For example, when a
learner has had a patient or family member with the same disease process, they may
23
reproduce appropriate nursing interventions more easily. Mental rehearsal, immediate
enactment, and feedback occur in simulation and debriefing which strengthens the
reproductive phase (Bandura 1977; Braungart & Braungart, 2008). The learner has
the opportunity to observe patient care actions and then to think about how they will
perform the same care. The learner is then able to perform care on the human patient
simulator and receive immediate feedback from educator and peers during debriefing.
The motivational phase focuses on the motivation of the learner to perform the
observed behavior (Bandura, 1977; Braungart & Braungart, 2008). Bandura (1997),
states that people motivate themselves by forming beliefs about what they can do,
anticipating outcomes, setting goals, and planning courses of action. In social
modeling, if the learner sees people like themselves succeed, they are more likely to
believe they can succeed as well (Bandura, 1997). The simulation and debriefing lab
increases learner confidence by allowing the learner to witness the success of fellow
nursing students. The educator can have a large influence on the motivational phase
by focusing on the positive aspects of the simulation, pointing out successful
interventions, and providing constructive feedback when mistakes are made. Learning
from feedback occurs when the educator is warm, open, engaging, and encouraging
(Davis, 2013). If people are persuaded to believe in themselves, they are more likely
to put forth more effort and to experience success (Bandura, 1997). The simulation
and debriefing educator will need to carefully consider each scenario and match the
learner with the correct objectives to avoid placing students in situations where they
are likely to fail. Experience with self-success, peer success, constructive criticism,
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and positive reinforcements can motivate learners to perform the observed behaviors
(Bandura, 1997).
Experiential Learning Theory
Experiential learning theory is a holistic perspective that combines
experience, perception, cognition, and behavior (Kolb, 1984). The focus of many
learning theories in simulation and debriefing are based upon the ideas of experience
and reflection (Neill & Wotton, 2011; Overstreet, 2008; Rothgeb, 2008). Overstreet
(2008) states that experiential learning is the foundation for nursing education.
Experiential learning is defined by Kolb (1984) as “the process whereby knowledge is
created through the transformation of experience” (p. 38). Kolb (1984) believed that
learning is a transformational process, continuously occurring. He focuses on the
experience as the central component in the learning process. His model, known as the
cycle of learning, is described as having two main dimensions which are perception
and processing. Within each dimension there are two opposing viewpoints. Within
the perception dimension are the concrete experience and the abstract
conceptualization. The process dimension includes reflective observation and active
experimentation (Kolb, 1984).
According to Kolb (1984), learning occurs in a four stage cycle (see Appendix
B). In the concrete experience stage the learner is actively engaged in an experience.
This experience creates the basis for the reflective observation stage in which a
reflection occurs based upon observations during the experience. During the abstract
conceptualization stage thoughts are explored and new plans for action can be
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created. These new plans can be tested in the active experimentation stage which
leads to new experiences. Experiential learning theory states that ideas are not fixed
but rather formed and continuously modified by experiences (Kolb, 1984).
The processes of simulation and debriefing are quite similar to Kolb’s cycle of
learning with experience, reflection, thinking, and performance taking place
throughout the process (Reed, 2012). Integration of the experience with reflection is
the basis of learning (Decker et al., 2013). Learners in the simulation lab are given a
patient scenario and are able to care for the human patient simulator which creates the
concrete experience. The learners also witness peers in similar situations caring for
the human patient simulator. Learners then move to the debriefing room where
discussions occur based upon the simulation experience which is the reflective
observation stage. During this discussion new concepts, ideas, and plans are created
which is the abstract conceptualization stage. Learners are then able to move forward
in the active experimentation stage to test these new concepts, ideas, and plans which
leads back to new experiences.
The reflective observation stage of Kolb’s learning cycle is a crucial element
of debriefing in nursing education. Many articles highlight the importance of
reflecting upon the experience to promote learning. Simulation experiences should
include a debriefing process that facilitates reflective thinking (Decker et al., 2013;
Fanning & Gaba, 2007). Reflection is defined as “the conscious consideration of the
meaning and implication of an action, which includes the assimilation of knowledge,
skills, and attitudes with preexisting knowledge” (Decker et al., 2013, p. s27)
26
According to Dreifuerst (2009), this is the time to consider thinking processes that
took place during the simulation. Reflection and subsequent analysis is the foundation
for experiential learning, followed by a new experience.
Theory as a Guide
Bandura’s social learning theory and Kolb’s experiential learning theory
provide guidance for educators to create an educational experience that will promote
learning. Many concepts from these learning theories will be incorporated into the
debriefing tool. Concepts obtained from Bandura (1977) include providing
participants with a complete and thorough orientation, creating a positive learning
environment, matching learner knowledge level with the scenario, allowing
participants time to develop a plan before beginning the scenario, using cues to guide
learning, ensuring there is learner awareness of actions taken during the scenario,
reflecting on emotions, giving feedback based upon observations, identifying the
value of the simulation, and exploring implications for future practice. These
concepts have become part of the debrief tool and will provide structure for the
debriefing process.
Concepts obtained from Kolb’s experiential learning theory (1984) follow the
cycle of learning. Creating the experience at participant knowledge level, discussing
the experience through guided reflection, exploring thoughts, identifying the meaning
and implications of actions taken, and creating new plans for future experiences are
all concepts that will be incorporated into the tool. These ideas have also become part
27
of the debrief tool. They will set the stage for learning to occur and guide the educator
to transform information into knowledge.
Learning theories provide a foundation from which the educator can build. It
is important to understand the way in which learning occurs during simulations and
debriefing in order to be a competent educator that is able to provide a positive
learning experience. Bandura’s social learning theory (1977) places emphasis on role
modeling and observation. Kolb’s experiential learning theory (1984) places
emphasis on the experience and reflection of the experience. The principles in both of
these theories can be applied to participants in simulation and debriefing. Simulations
allow students to observe, retain, perform, and reflect on real life patient scenarios.
These two theories provide a guideline for educating nursing students in simulation
and debriefing.
DEBRIEFING TOOL
Debriefing has proven to be a critical component to learning in simulation.
The approach used to conduct debriefing impacts the way that participants will learn
from the experience. The Debriefing Tool for Nurse Faculty will standardize the
approach used to debrief and will guide nursing faculty through best practices in the
debriefing process (see Appendix C). In creating the debriefing tool, attention was
given to several key areas including nursing faculty as facilitators of the tool, the use
of checklists as a debriefing tool, and incorporation of elements into the tool based
upon a review of the literature.
Debrief Facilitator
The role of nurse faculty in the debriefing process is that of the facilitator. The
facilitator has the most vital role in the dynamics of the experience for the learner
(Overstreet, 2008). Hayden, Smiley, Alexander, Kardong-Edgren, and Jeffries (2014)
indicate that best practices should be incorporated into the simulation program
including experts who conduct theory-based debriefing. Competency in debriefing
and the ability to engage students are important skills for the facilitator to
demonstrate (Dreifuerst & Decker, 2012). According to Cant and Cooper (2011), the
success of learning in debriefing depends on the facilitator, which highlights the
importance of training in debriefing techniques. It is imperative that facilitator skills
are in accordance with best practice (Cant & Cooper, 2011; Dreifuerst, 2009). The
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29
checklist guides facilitators to follow best practices by listing the key elements of
debriefing.
Debriefing is a strategy that facilitators need to master (Neill & Wotton,
2011). The debrief facilitator assists students in examining the meaning and
implications of the actions taken during a simulation. This process of reflective
thinking does not occur on its own, but must be guided by an effective facilitator
(Decker et al., 2013). These reflective learning processes lead to clinical reasoning,
critical thinking, judgment, and communication skills (Arafeh, Hansen, & Nichols,
2010). With the ultimate goal being to promote reflective thinking and to link
simulation with clinical practice, facilitator competence and standardization are
essential. Regular and consistent review of debriefing concepts will assist in
facilitator competency (Arafeh et al., 2010). The checklist will be provided for each
debriefing session, ensuring regular and consistent use by facilitators.
The importance of the facilitator role is evident for debriefing to be
successful. Such importance requires a responsibility to be competent in the
debriefing process and to follow best practices. The debrief tool assists in facilitator
debriefing techniques by providing a structured tool with essential elements to foster
learning. The tool provides organization and highlights the key elements of debriefing
proven to result in best learning outcomes.
Checklists
A checklist is defined as an organized tool that outlines criteria of
consideration for a particular process (Hales, Terblanche, Fowler, & Sibbald, 2008,
30
p.22). According to Kohn, Corrigan, and Donaldson (2000), methods used to reduce
errors include reducing reliance on memory, simplification, standardization, use of
checklists, and reducing reliance on vigilance. Checklists are used as cognitive aids to
provide guidance through task completion by highlighting important criteria, creating
standardization, enhancing objectivity and improving reproducibility (Hales et al.,
2008). Standardization reduces reliance on memory and assists those that are
unfamiliar with the process (Kohn, Corrigan, & Donaldson, 2000). Checklists seem to
provide protection against failures by explicitly identifying necessary steps
(Gawande, 2009).
According to Gawande (2009) there are good checklists and there are bad
checklists. Bad checklists are too long, vague, imprecise, and are hard to use. These
types of checklists spell out every single step, treating the user as if they were dumb.
Good checklists are easy to use by being precise, efficient, and to the point. They do
not detail everything but rather provide reminders of the important steps. Most
importantly, good checklists are practical (Gawande, 2009). Hales et al. (2008)
emphasize the importance of incorporating evidence based concepts into the
checklist. A literature review should be conducted and evidence-based best practices
should be considered to form the body of the checklist. Unnecessary images, color, or
text should be avoided. The overall checklist should provide key points while still
31
leaving room for the facilitator to use their own judgment. The checklist should be
clear, easy to use, and timely (Hales et al., 2008).
Following the above recommendations, and a review of the literature, the
Debrief Tool for Nurse Faculty was developed. Best practices for debriefing were
identified and used to create the body of the checklist. The checklist is clear, simple,
and timely. It is free from any additional information or unnecessary items.
Elements incorporated into the checklist serve as a guide rather than a monotonous
detailed description of each action. Lastly, the checklist is practical. This tool will be
used frequently by nursing faculty as the use of simulation continues to increase in
nursing education.
Tool Creation
To accomplish success in debriefing, consideration must be given to other
areas of the simulation experience. Expected outcomes can only be achieved when
there is preparation before, facilitation during, and debriefing after the simulation
event (Franklin et al., 2013). Aspects of the pre-brief and the simulation scenario have
particular relevance to the debriefing session (Arafeh et al. 2010). Success in
debriefing requires careful planning and consideration well before debriefing takes
place. At first glance the checklist may appear to be more than a debriefing tool,
however, each element was included because they will have a direct impact on the
debriefing session. Due to the fact that each of the content areas are interrelated and
directly affect one another, they must be considered in the checklist. For example, if
the facilitator fails to develop a safe environment of confidentiality and trust, the
32
learners will not engage during the debriefing session because they will not feel safe
to do so. The content areas that emerged from the literature include general
preparation, pre-briefing, simulation, and debriefing.
General Preparation
The simulation environment, debriefing environment, and timing are areas to
consider in the general preparation content area. The literature identifies general set
up of the environment as an important factor of the simulation experience (Cant &
Cooper, 2011; Center for Medical Simulation, 2013; Jeffries, 2005; Wickers, 2010;
Zigmont, Kappus, & Sudikoff, 2011). The debriefing checklist includes increasing
fidelity within the simulation environment. Facilitators can increase realism in
several ways including requesting that students dress in clinical attire (Wickers,
2010), matching simulators to the scenario, and by using staging props in the
environment to create a realistic setting (Rothgeb, 2008). According to the Center for
Medical Simulation (CMS), the facilitator should make the simulation environment as
real as possible within resource and technology restraints (2015). Facilitators should
discuss with participants the idea of treating the simulation as if it were real, to the
best of their ability (CMS, 2015; Rudolph, Raemer, & Simon, 2014). Rudolph,
Raemer, and Simon (2014) found that learners are more likely to focus on the goals of
the simulation when fidelity and realism were addressed and approached fairly by the
facilitator.
The debriefing environment and timing will also impact the debriefing
session. The debriefing checklist indicates that the environment should be a
33
comfortable, intimate setting with seating arranged to facilitate conversation. It is
important to create an environment that will stimulate group discussion (Wickers,
2010). The room should be private, arranged in a circular design, and have adequate
space for the number of participants (Decker & Dreifuerst, 2012).
Timing is an important consideration in general preparation (Cant & Cooper,
2011; Chronister & Brown, 2012; Jeffries, 2005; Reed, 2012). The debrief checklist
indicates that preparations should be made for the debriefing session to last 2-3 times
longer than the scenario, or longer if video feedback will be given. According to
Arafeh et al. (2010) the debriefing is usually 3 times longer than the simulation. The
length of time used to debrief will depend upon several factors such as learning
objectives, learner level, outcomes, or time constraints in schedule (Dreifuerst &
Decker, 2012). Verbal methods of debriefing may play more of a role in knowledge
retention than video assisted (Chronister & Brown, 2012), therefore video playback
should not be used in place of verbal debriefing, but in addition to it.
Pre-briefing
The pre-briefing content area includes the steps that should be taken before
the simulation experience occurs. This is the period of time when the facilitator
introduces the students to the simulation experience. Rudolph et al. (2014) states that
the pre-brief has a significant impact on student engagement. A thorough introduction
can improve participation and learning, decrease complaints and disengagement, as
well as reduce defensiveness and resentment in simulation and debriefing (Rudolph et
al. 2014). A thorough student orientation is an essential component of a successful
34
debriefing (Arafeh et al., 2010; Cant & Cooper, 2011; CMS, 2013; Fanning & Gaba,
2007; Franklin et al., 2013; Reed, 2012; Wickers, 2010; Zigmont et al., 2011).
Providing participants with a thorough orientation will improve self-efficacy and
increase chances of success (Bandura, 1997). There is a significant amount of
information provided during the pre-briefing session to adequately orient the students
to the simulation and debriefing experience.
The purpose of the simulation, learning objectives, and expected outcomes
should be covered in the beginning of the pre-briefing session. Learning objectives
should be used as a guide in simulation and debriefing (Cant & Cooper, 2011;
Chronister & Brown, 2012; CMS, 2013; Franklin et al., 2013; Jeffries, 2005; Zigmont
et al., 2011). According to Franklin et al. (2013), the objectives should guide
preparation before the simulation, facilitation during simulation, and debriefing after
simulation. Jeffries and Rogers (2012) state that objectives must specify expected
learner behaviors, reflect intended outcome, and include sufficient detail for learner
success. Expected outcomes are also an important component in simulation and
debriefing (Cant & Cooper, 2011; CMS, 2013; Franklin et al., 2013; Jeffries, 2005).
While objectives guide the development and implementation of the experience,
outcomes will provide an assessment of performance and clinical reasoning of the
participants (Decker et al., 2013).
Confidentiality and trust are also essential for a successful debriefing (Arafeh
et al., 2010; CMS, 2013; Fanning & Gaba, 2007; Rudolph, Simon, Dufresne, &
Raymer, 2006; Wickers, 2010). Gloe et al. (2013) indicate that confidentiality of the
35
performances, scenario content, and participant experience is required during and
after any simulation. Confidentiality applies to all aspects of the simulation
experience, the debriefing, any feedback provided, and all patient information made
available to the participants. Lack of professionalism and mutual respect will
negatively affect the experience and reduce learner engagement (Gloe et al., 2013).
To ensure a successful debriefing, learners must feel valued, respected, and free to
learn in a dignified environment (Fanning & Gaba, 2007). Debriefing can only begin
if the facilitator has created a safe learning environment (Wickers, 2010).
Facilitation in the pre-briefing area includes setting the learners up for success
to meet the learning objectives. It is important to describe the debriefing process,
roles, and expectations including the expectation that participants will perform at their
optimal best while acknowledging that mistakes may be made (Franklin et al., 2013).
Learners may be unfamiliar with the normal processes and roles of simulation and
debriefing, therefore it is important to clarify these concepts (Rudolph et al., 2014).
Orientation to the equipment, the environment, the scenario, and allowing participants
time to develop a plan will assist students in performing well and meeting learning
objectives (Franklin et al. 2013). When participants are expected to do well, and
they are given the guidance and support they need to succeed, they do succeed
(Jeffries & Rogers, 2012).
Simulation
The actual simulation experience has a direct impact on the debriefing
process. Simulation is most effective when careful planning occurs (Middleton,
36
2012). Learner needs, experience level, and expected outcomes guide the methods
used in simulation (Franklin et al., 2013). Learning objectives should be clear,
referred to often, and used to conduct the simulation (Jeffries, 2005). These same
learning objectives should be reviewed during the debriefing session (Decker et al.,
2013). Franklin et al. (2013) states that expected outcomes should be developed to
ensure learning objectives are met. Planning when to incorporate cues in to the
scenario to lead participants towards expected outcomes should also be provided.
Cues alert participants to a particular issue such as laboratory results, phone calls,
family member input, or patient verbalization (Franklin et al, 2013; Jeffries & Rogers,
2012). These cues should offer enough information for the learner to continue in the
simulation without interfering in independent problem solving (Jeffries & Rogers,
2012). The cues should coach the participant, which leads to achieving expected
outcomes (Franklin et al., 2013). The expected outcomes will be discussed during the
debriefing session.
The simulation experience provides the concrete experience necessary for
learning to occur in the debriefing session. According to Kolb’s experiential learning
cycle (1984), the experience sets the stage for learning to occur during reflection. The
actions taken during the experience will be the foundation for the reflective
discussion that occurs during debriefing. This discussion explores thoughts, identifies
37
meaning and implications, and explores new plans for future experiences (Kolb,
1984). The simulation experience will be the foundation for the debriefing discussion.
Debriefing
Research has shown that the debriefing process is where the majority of
learning occurs in simulation experiences (Mariani, Cantrell, Meakim, Prieto &
Dreifuerst, 2013; Shinnick, Woo, Horwich, & Steadman, 2011). For learning to
occur, several key elements must be incorporated in the process of debriefing.
Although the literature provides a wide range of methods for debriefing, the general
processes are relatively the same. The process of debriefing should follow a common
flow with immediate reactions and emotions explored first, followed by reflection,
feedback, integration, and assimilation. Each element will be discussed in further
detail below.
The beginning of the debriefing should start with a review, followed by a
reaction. As stated previously, clarity is crucial to participation (Rudolph et al., 2014),
therefore a quick review of the debriefing process, roles, and expectations should be
discussed at the beginning of the debriefing session. As with all steps of learning,
objectives and expected outcomes should guide the discussion (Decker et al., 2013).
Initially, immediate reactions should be explored to allow students to vent their
feelings and reactions to what occurred during the simulation (Arafeh et al., 2010).
This period of time allows participants to relieve stress by discussing their feelings.
Participants may not be able to move forward with learning until they have discussed
their immediate reactions and emotions (Zigmont et al., 2011). Following this stage, it
38
is important for participants to describe the events that occurred during the simulation
to ensure all participants have the same understanding of the scenario as the
discussion moves towards reflection (Middleton, 2012; Zigmont et al., 2011).
The next step in debriefing is reflecting upon the experience. Reflection is
defined as “the conscious consideration of the meaning and implication of an action,
which includes the assimilation of knowledge, skills, and attitudes with preexisting
knowledge” (Decker et al., 2013, p. s27). Reflective learning is prevalent in the
literature as an important component of learning in debriefing (Arafeh et al., 2010;
Cant & Cooper, 2011; CMS, 2013; Decker et al., 2013; Dreifuerst, 2009; Dreifuerst,
2010; Fanning & Gaba, 2007; Reed, 2012; Rothgeb, 2008; Rudolph et al., 2006;
Zigmont et al., 2011). Zigmont et al. (2011) state that the purpose is to analyze and
evaluate performance through reflection, discover mental models or rationale for
specific behaviors, and to identify gaps and/or matches between existing and targeted
mental models.
Feedback is the next component of debriefing. Constructive feedback is
identified in the literature as an important part of the debriefing process (Cant &
Cooper, 2011; CMS, 2013; Dreifuerst, 2009; Reed, 2012). Participants notice the
effects their actions have, create assumptions about which actions are most
appropriate, and then base future actions upon those observations (Bandura, 1977).
Feedback is essential in identifying the most appropriate actions in a given situation.
The process is not just feedback on performance but rather a communication process
that draws out explanations and provides strategies for future practice (Cant &
39
Cooper, 2011). Positive aspects in providing feedback include clear, concrete
statements about participant performance and expected outcomes (CMS, 2015).
Strengths and challenges should be discussed in a non-threatening manner
(Dreifuerst, 2010). The goal is to investigate the how, what, and why of learner
thinking and actions. The key to identifying thinking processes and rationale for
actions is to engage learners in a conversation through inquiry. Once the thought
processes and rationale for actions are discovered, the facilitator can identify gaps and
opportunities for learning (Zigmont et al., 2011). It is essential that the facilitator
assist the learner is closing these performance gaps (CMS, 2015). Feedback is
imperative as actions will not change based upon observations alone, or experience
alone, but rather an incorporation of both guided by feedback (Bandura, 1977).
Integration of the new knowledge obtained from the experience with previous
knowledge is the next step in debriefing. The facilitator will need to embed the
elements of the experience into a framework the learner is familiar with, such as the
nursing process, so that knowledge can be called upon in future situations (Dreifuerst,
2010). Bandura (1977) states that retention of information is essential as actions
cannot be affected if learners cannot remember. The learners must make sense of the
experience and relate it to their own world (Fanning & Gaba, 2007).
Assimilation is the last phase of debriefing and is the ultimate goal of
debriefing. The learner demonstrates successfully that they can transfer what they
have learned from the simulation experience to clinical practice (Driefuerst, 2009).
Linking theory to practice is prevalent in debriefing literature (CMS, 2013;
40
Dreifuerst, 2009; Dreifuerst, 2010; Middleton, 2012; Reed, 2012; Zigmont et al.,
2011). For learning to occur there should be apparent links made between the
simulation, nursing knowledge, and patient outcomes (Dreifuerst, 2010). A discussion
regarding how the new knowledge can be used in actual practice will help learners
make those connections (Zigmont et al., 2013). Facilitators should discuss with
participants techniques that can improve their future performance and new ways to
think about and solve clinical problems.
A summary of the learning that occurred should be reviewed with participants
at the end of the debriefing session (Arafeh et al.; CMS, 2015; Zigmont et al.). This
should be a brief review of the topics that were discussed during the debriefing and
the solutions that were revealed (Zigmont et al., 2011). The summary is significant
because it serves to reinforce learning objectives and highlights key take-away points
for the learners.
The debrief checklist was developed to guide best practices in debriefing.
Consideration was given to nursing faculty as facilitators of debriefing and users of
the debrief tool. The checklist was developed based upon best practices as identified
in a review of the literature. Elements of the checklist include general preparation,
pre-briefing, simulation, and debriefing. These four sections of the checklist were
developed due to the impact each area has upon debriefing. When preparing for
debriefing, it is essential to consider the effects that other content areas may have on
41
the debriefing session, and to plan accordingly. The debrief checklist is an organized
tool that can be used to standardize debriefing using best practices.
EVALUATION
Evaluation is a critical step in the implementation of the debriefing tool. One
of the first, and most important steps in evaluation is to determine the purpose of the
evaluation (Adamson, Jeffries, & Rogers, 2012). The debriefing tool was developed
to guide facilitators through the debriefing process following best practices to
maximize participant learning. It is important to evaluate whether or not this is
occurring, or if any changes need to be made to the tool. To evaluate means to
determine the significance, worth, or condition of something, usually by careful
appraisal and study (Evaluation, 2015). According to the Center for Disease Control
and Prevention (CDC), a strong evaluation will consider the merit/quality, the worth/
value, and the significance/importance of something (CDC, 2015). Debrief facilitators
and debrief participants will evaluate the debriefing process in different ways. Two
evaluation tools were developed to assess the effectiveness of the debriefing tool from
both perspectives.
Facilitator
Facilitators will be the users of the debriefing tool, therefore they will be
evaluating the actual tool as well as their experience using it (see Appendix D). The
quality of the tool will be assessed with evaluation questions related to ease of use,
relevant content, missing items or gaps in any content area. The value of the tool will
be assessed with evaluation questions related to helpfulness of the tool during general
debrief preparation, pre-briefing, simulation, debriefing, and guidance through
42
43
relevant topics. The importance of the tool will be assessed with questions related to
meeting expected outcomes, participant learning, and linking theory to practice. This
tool is a combination of a Likert scale ranging from 1-5 based upon strongly agree to
strongly disagree to the statements presented, in addition to free space for additional
comments.
Participant
Participants will evaluate their overall experience with the debriefing session
and the performance of the facilitator (see Appendix E). The quality of the debriefing
will be assessed through questions related to orientation, purpose of simulation,
comfort level, and opportunity to communicate. The value will be assessed through
questions related to application of knowledge, least helpful aspects of the experience,
and suggestions for improvement. The significance will be evaluated through
questions related to concepts that were learned, reflection, and linking theory with
practice. The participants will also evaluate the impact that the debrief facilitator had
on learning. This tool is a Likert scale ranging from 1-5 based upon strongly agree to
strongly disagree, in addition to open-ended questions.
Implementing an evaluation plan should always be developed to ensure that
the strategy is effective and that students are indeed learning from the activity
(Adamson et al., 2012). The information obtained from both the faculty and the
learner evaluations will be used to modify or strengthen the debriefing tool.
Feedback will be obtained after each debriefing session. This data will be used by the
44
simulation coordinator to improve the debrief tool with the ultimate goal being to
increase positive learning outcomes.
Summary
Simulation continues to increase in nursing education (Hayden, Smiley,
Alexander, Kardong-Edgren, & Jeffries, 2014), with the greatest gain in learning
occurring during the debriefing process (Shinnick, Woo, Horwich, & Steadman,
2011). The purpose of this project was to develop a tool for nurse faculty to guide
best practices in debriefing. The ultimate goal being to standardize the debriefing
process following best practices to optimize learner outcomes. A review of the
literature was conducted to identify best practices. Although practices vary, the
literature revealed many common concepts that are essential for an effective
debriefing. These concepts were used to develop the body of the debriefing tool.
Bandura’s social learning theory (1977) and Kolb’s experiential learning theory
(1984) serve as guides for learning processes that occur in simulation and debriefing.
Concepts from both theories were implemented into the debriefing tool. A checklist
format was chosen for several reasons including simplicity, objectivity,
reproducibility, and the ability to serve as a standardized guide for best practices. The
debrief tool will be used with future simulations and debriefing experiences. An
evaluation of the debriefing tool and the overall experience will be obtained from
both the learners and the facilitators. Data obtained from the evaluations will be used
45
to modify and strengthen the debriefing tool. This project will be an ongoing process
to enhance future debriefing experiences and improve learner outcomes.
Debriefing is known to be crucial to the learning that occurs in simulation, yet
debriefing methods vary greatly. Future research should focus on standardization of
the debriefing processes following best practices. Implementation and evaluation of
this tool, as well as others, should be explored.
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47
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APPENDICES
55
APPENDIX A
BANDURA’S PHASES OF LEARNING
Attentional Processes
Retention processes
Modeling Stimuli
Distinctiveness
Affective Valence
Complexity
Prevalence
Functional Value
Symbolic Coding
Cognitive
Organization
Symbolic Rehearsal
Motor Rehearsal
Motor Reproduction
Processes
Physical Capabilities
Component Responses
Self-Observation
Accuracy of Feedback
Motivational
Processes
ExternalReinforcement
VicariousReinforcement
Self-Reinforcement
Observer
Characteristics
Sensory Capacities
Arousal Levels
Perceptual Set
Past Reinforcement
Bandura, A. J. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice Hall
Bandura’s phases of learning outline the processes of observational learning. Learners
observe modeled events, follow the phases of learning, and conclude with matching
performances of observed behaviors.
56
APPENDIX B
KOLB’S CYCLE OF LEARNING
•New simulation or
clinical experience
•Formation of
new concepts,
ideas, and plan
•Simulation
experience
#4- Active
Experimentation
(trying out what you
learned)
#1- Concrete
Experience
(having an
experience)
#3- Abstract
Conceptualization
(learning from
experience)
#2- Reflective
Observation
(reflecting on the
experience)
•Debriefing
session
57
APPENDIX C
DEBRIEF TOOL FOR NURSE FACULTY
58
APPENDIX D
DEBRIEF TOOL: FACULTY EVALUATION
Directions: Please circle the most appropriate answer to each question.
Debrief Tool
Strongly
Disagree
Disagree Undecided
Agree
Strongly
Agree
The tool is easy to use
1
2
3
4
5
The tool is thorough, containing
all relevant content areas
The tool was helpful in general
preparation of debriefing
The tool was helpful in pre-brief to
prepare for debriefing
The tool was helpful in simulation
to prepare for debriefing
The tool provided guidance for me
during the debriefing session
The tool helped participants to
meet the learning objectives
The tool helped participants to
meet the expected outcomes
Participants were guided to link
theory with practice
I will use this tool in the future
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
No changes to the tool are needed
1
2
3
4
5
My over-all experience using the
tool was positive
1
2
3
4
5
Comments: Please comment below on any area you rated 3 or less
Additional Comments:
59
APPENDIX E
PARTICIPANT EVALUATION
60