I am growing more and more concerned about the pacifism by which I hear people approaching their debriefing efforts as I travel about the world. The phrase “safe learning environment” is being hijacked into some sort of process during which the only thing that matters in the world is the feelings of the learners participating in the simulations. So much so that some are saying you shouldn’t tell students what they didn’t do correctly and that during debriefing you should only focus on that which went well and then have a group hug at the end. This is being claimed under banners of student centric debriefing, “safe learning environments”.
Do these same educators harbor the fear and trepidation that students might be sad if they perform poorly on a written test? Do these same educators realize what a disservice they are doing for the students when you step back and look at the big picture? Maybe the educators themselves have a tough time bucking up and delivering the news, doing the HARD WORK of simulation. Perhaps, this shifting or trending is partly evolving because many of the people involved in the teaching and theorizing about simulation feedback don’t see patients on the frontline of the healthcare battlefield.
I am certainly not advocating that we don’t need to be mindful of students emotions and psychological well being during simulation education activities, but come on people, healthcare decisions and actions involving patient care need to be near perfect. Every Time. We need to be certain that when participants leave our simulations they have a clear understanding of what was right and what was wrong not just do a deep dive into their feelings carefully guarded by the emotions police and find happy things to chat about.
I am sorry to be the bearer of bad news, but providing healthcare is hard work, stressful and requires excellence. We need to develop/reinforce excellence in the participants of our simulations and help them achieve their goal, which is to get better at what they do. Every healthcare professional in the world has this as a goal at some level. How we reach out to them and help them along this journey needs to be PATIENT CENTRIC because the ultimate goal is to continuously improve healthcare throughout the world.
We certainly must develop methods consistent with the levels and abilities of our simulation participants and create environments that are open to participating, learning, exploring and discussion. But we also must provide participants with information on where they are with regards to expected performance on a continuum of the development of competence. We can not hide the truth during a debriefing because the faculty is uncomfortable with delivering critical feedback, or is so concerned that the students emotional fragility will be violated if they receive the feedback. This is a violation of our ultimate relationship with the ultimate beneficiary of healthcare simulation, the patient.
During debriefings it is incumbent upon us to make sure that students are treated fairly, treat each other fairly and help to discover things needed for improvement through creating reflections on the learning activities. We also need to make sure there is crystal clarity on expected outcomes versus perceptions of performance that are reconciled. We also must guide the debriefing process in a way that is mindful of the psychological safety of the involved. I think this can be done with adequate training, re-training and continuing practice with the art of debriefing. When we achieve this, we have arrived at Patient Centered Debriefing, and that’s a place I think we all want be.
I do believe most professionals want to know what they did well as well as what they didn’t. They are the fundamental elements of being able to reflect and improve. We need to be able to have the message delivered by either a process of self-discovery, perhaps through facilitated reflection, or at other times, but just directly providing the information. This doesn’t mean it has to be harsh, or without the feelings of the person involved carefully considered, but it does mean it has to happen with a level of deliberateness that is unequivocal. It is the true art of the debriefing to be able to lead this effort and achieve these goals.
Finally I’ll close with a quote from my twelve-year-old son about one of his baseball coaches, “Dad, why does coach always tell me I did a good job when I know I messed up?” What is the answer? Not sure, but I hope that the coach doesn’t change careers and become a simulation facilitator for healthcare professionals.
I completely agree indeed a lot of time does often have to be spent empowering educators to actually give a realistic debriefing – there seems to be a mantra that learners cannot do things badly – this often results with them dropping hints, talking around issues or ignoring them. The learners often are aware they have not performed ideally and want this information clearly this does need to be performed in a situation where the learners do feel they can voice their fears, concerns or questions.
I agree with your analysis. Everyone cannot be a winner all of the time. Improvement can only happen when errors are pointed out along with developing strategies for professional growth. There are no do-overs in real-life and constructive criticism is an appropriate means to that end. If the stress of a debrief in a simulated scenario is too much to bear, what will happen when they are practicing in the field?
Healthcare delivery is changing and the emphasis is on quality and providing value to our patients. That value will ultimately be measured by our patients and families and it will be graded on how well we return them to a more normal state of health and function.
Competent practitioners are what’s needed, not people who wither in the face of criticism…
Amen, Paul! There is a huge amount of skill that goes into debriefing. Not everyone is an effective debriefer, just as everyone is not an effective facilitator. Why do educators think that mastery learning and repetitive practice doesn’t apply to them? Kim
Paul,
Thank you for writing this and stimulating a conversation that has needed to happen. I do agree with the philosophy that there is an emotional state when one is engaged and positive that leads to improved learning. However, some learners embrace feeling uncomfortable and engaged in a safe environment and know that their debriefing faculty are there to guide their future patient care activities. I have witnessed too many simulation sessions where performance gaps are left unaddressed in the interest of preserving a participants’ feelings.
I have always said I can say whatever I want to my learners as they are ravenous for as much information and guidance as possible and most of the time ask me to get rid of the “filler”. I know the debriefing style that we use does make a difference. I hear countless accounts of patient encounters that occur after simulation sessions and has made an impact in the ability to communicate and lead or the knowledge of the physician. We often talk of “evaluation” of a program as a survey collected from participants. However, according to Kirkpatrick, the highest form of evaluation (Level 4) relates to outcomes in the real world, improved quality, return on investment, cost reduction and avoidance of errors.
I believe this is why we sim. It is so powerful to hear our learner’s accounts regarding how they apply their knowledge gained in sim. I believe in patient centered debriefing. We need to continue to strive to understand what works and why in our debriefing styles.
Thanks again for writing this piece.
Sharon
Excellent post Paul! Kudos and I agree 100%. One of my colleagues, an excellent debriefer, prepares her learners for simulation and debriefing by saying ” I am going to to purposely be seeking gaps in your performance, to help you provide safer patient care in the future. We will address these gaps in debriefing, as well as what you did well.” This approach has decreased learner anxiety and has allowed the good, the bad, and the ugly to be addressed in each and every debriefing. Learners know they are getting honest feedback and how to be better next time. it refocuses them on WHY they want to be better next time…it is not about us, it is about the patient.
I would hate to see simulation evaluation co-opted the way traditional clinical evaluation has been, for so many nursing faculty. Fear of lawsuits and the accusation of a subjective appraisal for poor clinical performance, subsequently overturned by a lead faculty or director, have made it almost impossible to fail anyone clinically. At least in simulation, it is crystal clear what someone knows and does not know, as long as we are honest in our debriefing. Jenny Rudolph et al. have an excellent article on this topic in the October 2013 issue of Simulation in Healthcare.
Hi Paul,
Excellent article. I am in complete agreement with you about being honest during debriefing (participants can always tell when we’re not I think)
I suppose it depends on what people mean when they say ‘safe’ – I agree that it shouldn’t mean ‘never giving a negative feedback’! which would make our participants ‘unsafe’ in the real clinical world.
I do feel however that it’s important to provide a supportive environment where participants feel safe enough to share their perspectives and so we get a chance to see where the ‘problem’ was that led to a particular undesirable behaviour during a scenario.
I still use the word ‘safe environment’ and by that I mean when we give negative feedback, it is without shaming and blaming or scolding which is still predominant in my culture – as when this happens participants just clam up, nod their heads in agreement and continue to miss the point because they’re too scared to clarify their misunderstanding.
Perhaps I need your expert input on what’s a better term to describe the above approach. Patient-centered in my culture may still mean participant-bashing