Tag Archives: feedback

May 26, 2023 · 1:17 pm

Simulation Professionals: Don’t let the Vocal Minority Get You Down!

The social psychologist Barbara Fredrickson coined the phrase, “The negative screams while the positive only whispers.” I don’t know about you, but this is extraordinarily true when reviewing course evaluations after simulation-based education programs!

Post-course evaluations are essential in measuring the program’s effectiveness and participant perceptions and are a tool to help with quality improvement initiatives. However, the feedback from vocal minorities can sometimes overshadow the opinions of the silent majority. After pouring blood, sweat, and tears into creating what you believe to be a successful simulation-based program, it can sometimes be a blow to your motivation when you receive negative evaluations.  At times the feedback can be pithy and personal and can sting.

Receiving negative feedback can be challenging for many reasons. First and foremost, it can feel like a personal attack on the hard work and effort you’ve put into a project or program. It’s natural to feel defensive or upset when someone criticizes something you’ve put so much time and energy into creating. Additionally, negative feedback can be difficult to process and use constructively. It’s easy to get caught up in the moment’s emotions and feel overwhelmed by the criticism. This can make it difficult to see the feedback as an opportunity for growth and improvement rather than a setback or failure.

This can be problematic as the feedback may not accurately represent the actual experiences of most participants, but it can certainly feel that way. It is also important to recognize the opportunities that come with critical feedback that could help you improve your program. It can help educators and course designers to identify areas for improvement and develop strategies for addressing these areas. Particularly when it is delivered constructively, and with a focus on improvement, negative feedback can be a powerful tool for enhancing the quality of simulation-based education programs and developing resilience in educators and learners alike. Critical feedback can help to identify areas for improvement, develop new strategies, and implement changes that can benefit future participants.

It is also important to remember that most participants with positive experiences may not feel the need to provide feedback. In contrast, those who have negative experiences may be more inclined to do so. So, I challenge you to go back and look at the designs of your course evaluation tools. It’s important to remember that the silent majority can be an important ally in the success of your program. By actively seeking out their feedback and insights, you can ensure that your program is meeting the needs of all participants, not just the most vocal. I’m not suggesting that we ignore the critical feedback; we just must find a way to balance it into a healthy model that contributes to resilience.

Developing a growth mindset is essential for developing resilience for those running simulation programs. It involves embracing challenges and staying motivated even when things get tough. Instead of seeing failures and setbacks as signs of inadequacy, individuals with a healthy mindset view them as opportunities for growth and learning. One powerful tool I use is remaining patient-centric in the decisions made regarding our simulations. Thinking about the downstream benefits that help raise the quality-of-care patients receive because of our efforts helps to keep my eye on the ball.

Lastly, remember that we can’t be all things to all people. While we remain excited and recognize the power of simulation-based education, not everyone will share our enthusiasm. As we move forward, remember that we can learn from the naysayers and the people unhappy that they are required to participate in some of our programs. Try to avoid the negative screaming in your ear, and you mistakenly believe that it represents the majority opinion. Stay focused on the idea that patients will benefit from our efforts, and many participants likely perceive value from our efforts.

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November 24, 2021 · 3:21 pm

Adjuncts to Enhance Debriefing

I wanted to discuss some ideas of using adjuncts as part of your debriefing.

When we think about debriefing, we often think about a conversation between faculty member or members and participants of simulation with a focus on everyone developing an understanding of what they did right as well as what they need to improve upon.  We rarely think about the possibility of including other “things” to enhance the learning that comes from the debriefing.

I tend to incorporate adjuncts into a many of the debriefings associated with courses that I design.  What I mean is things that added into the debriefing process/environment that can enhance the discussion.  Sometimes with deliberate purpose, and other times just to mix it up a little bit so that it is not just a dialogue between the participants and the faculty.  It may be something technical, it may be something as simple as a paper handout.

Simple Task Trainer as an Adjunct

Some ideas of adjuncts include PowerPoint slide deck or a few targeted slides that help to review a complex topic, one that requires a deeper understanding, or a subject that benefits from repetition of exposure.  Another type of adjunct is the simulator log file which can help set the stage for the debriefing and create a pathway of discussion that chronologically follows what happened during the simulation.  Another adjunct could be a partial task trainer or a model that helps to describe or demonstrate something.  For example, the students forgot to do a jaw-thrust or open the airway.  We can use a task trainer, or a teaching aide incorporated into the discussion during the debriefing.  

Example of an Algorithm Poster on the Wall

Other things that I use are charts, graphs, and algorithms that may represent best practices.  When I debrief during my difficult airway management course for physicians, I have the algorithm up on the wall hanging as a poster.  We use the algorithm posters as a pathway to compare the performance of the participants of the simulation with what the ideal case would be.  You can use the adjunct learning aid as a reference to standards.  This can help you to take yourself out of the direct argument of right vs. wrong.  This allows use of the adjunct as a third-party messenger of a reference to best practices excellence when I have the participants compare their performance against what appears on the algorithm.  This allows them to discover their own variations from the expected standard.  It tends to create powerful learning moments without the faculty having to be “the bearer of bad news!”

I think that if you start to strategically think about how to incorporate adjuncts into your debriefing you will find the students are more satisfied with the debriefing.  It also increases the stickiness of the learning and creates a more enjoyable experience for the faculty member as well as the participants.  Try it!  It does not have to be fancy!

Thanks, and as always,

Happy Simulating!

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August 19, 2019 · 11:50 am

Five Pearls for Debriefing 

Sharing some practical considerations to help you with your debriefing efforts!

 

Shell with a pearl

1. Before you begin attend to learner readiness 

Before you begin ensuring the emotional readiness of your learners will be a huge benefit. Learning during a debriefing can be enhanced by reducing distractions. Such distractions can occur from many possible origins. If learners are particularly stressed, angry or perhaps sad after a simulation experience it is best to let them process their emotions or otherwise emotionally and mentally prepare themselves to be able to focus on the content of the debriefing. So, taking a few minutes to observe, or perhaps even directly asking, “Are you ready?” may go a long way. Also, another tool that I use after a stressful simulation is to just acknowledge that there may be stress with a statement such as “Wow. That looked stressful. Are you guys ready to talk about it?” 

2. During the debriefing, listen to the learners, analyze their thoughts and understanding 

A structured debriefing should provide the opportunity to listen to learners. This allows the debriefer to analyze if the learners have a command of the facts and understanding of the intended learning associated with the simulation. It is easy to become impatient with the process and start telling the learners what they need to know. Once this occurs, it is difficult to assess what the learners do know and understand. As you listen to learners during the debriefing think about what you need to ask next, or where you need to take the conversation to be able to analyze the next area of content you wish to explore during the debriefing. So another tip is shift your thoughts to how can I discover if my learners know….. as opposed to the normal transmittal of information that comes from thinking I need to tell them X, Y and Z so that they understand. 

3. What went right is as important as what went wrong 

There is a saying that the negative screams and the positive whispers. This could not be truer when it comes to debriefing. It is far easier to remember what people did wrong during a scenario, then what they did right. But if you sit back and think about it, they are equally as important. Learners leaving a debriefing understanding that they did correctly and why it was correct, paired with an understanding what they did wrong and why it was wrong is critically important for improvement to occur. If the right things are not debriefed, it may be that they were done out of habit or luck and that the learners don’t understand it at all! Or worse yet, they could be perceived as unimportant. So a good tip is to jot some noted down of things that went correctly during a scenario. Trust me, you’ll remember all those mistakes which will be screaming! 

4. Keep the debriefing focused 

A challenge for anyone conducting a debriefing is to keep things focused. Learners love to talk about what learners want to talk about. However, it’s important as the facilitators of the conversation that we have the learners talking about what they need to be talking about. What learners need to be talking about should be driven by the learning objectives of the scenario. This direction needs to come from the debriefer. There is a delicate relationship that exists between the learners and the debriefer so carefully thinking about how to maintain this but being able to gently nudge the conversation back to the right pathway is a skill worth concentrating on. A tip is to develop some scripts that you are comfortable using when such nudging need to occur.  

Consider this example, “I agree that the exact dosage of the medication is critically important, but for this scenario and debriefing we are tasked with focusing on the effectiveness of the communications within the team. So, who can give me an example of effective communications that occurred during the scenario?”  

 5. Bring out summary/take home points 

Every simulation has a plethora of opportunities for learning. It is the job of the debriefer to ensure that the primary learning objectives of the simulation are covered. During complicated cases or cases with multiple learning objectives it is possible to cover a lot of ground along with many topics and facts during the time when you are analyzing the learners grasp of the content. It is important to close with summary points that are crucial take home messages. This can be challenging for some, and often turns into a mini lecture. And remember when you start lecturing to the learners, you are sacrificing the ability to ensure understanding where the learner is at that point and time. Concluding or beginning the wrap up of the debriefing by asking leaners to give one or two things that they think went well during the scenario along with what they would  change next time can be an effective probe into understanding that the learners took away the big learning messages. It also serves as the time to allow you to shape the discussion with further questions that drive home the intended take away points. Always think to yourself what are the two or three things that I want them to remember most from this experience a month from now. 

Well that’s is for now. Remember debriefing gets better with practice, feedback and experience. So, get out there, debrief, get some feedback and debrief again! 

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June 28, 2018 · 2:07 pm

Five Tips for Effective Debriefing

There is no doubt that debriefing is an important part of simulation-based education efforts. Further, to do a good debriefing is not necessarily easy. Practice, self-reflection and getting training can help dramatically.  Seeking out help form experts and experienced people can be invaluable. Also, there are many resources in which to learn more about debriefing. I encourage you to take advantage of them!

Here are just five random tips in no particular order to help you increase the effectiveness of your debriefing!

5tIPS

  1. Know what the goal(s) are. Be specific.

Too many times simulation scenarios are executed and the faculty member just kind of winging it during the debriefing. It is far more effective a strategy to be keenly aware of what the learning outcomes and goals are prior to the simulation. This will allow you to focus your thoughts and ideas on helping the participants get better during the simulation which can be carried forward to your debriefing efforts. If you are attempting to have the debriefing constrained to the learning objectives for the simulation it is often easier to organize the information and get across the salient points that are needed to achieve the learning outcomes. It is particularly important to remember that you can’t teach everything with every scenario. The participant brain can only take in or process so much information in any one setting. In this case think of a sponge completely saturated with water, that can’t take any more!

  1. Have a framework or structure in mind

Having a structure to your debriefing ahead of time, or perhaps adopting a model of debriefing can help you significantly overcoming the challenging parts of debriefing. Some of the challenges occur in organizing the information. There are a number of debriefing models out there for consideration of adoption. There is no reason to believe that one is better than the other. I highly recommend that you learn several models and become comfortable with them. What you’ll find is some models work better than others in varying situations based on s number of factors such as the experience and expertise of the debriefer, the subject matter that is the focus of the simulation, as well as the level of the learners.

  1. Involve all the learners

If you are debriefing a group of students a challenging task can be involving all the learners. Often times there will be one or two learners who engage in a dialogue with the debriefer and without conscious effort and skill it is easy to continue the dialogue and allow the other members of the participating team to feel potentially marginalized. Often times this dialogue occurs with the person that was in the “hotseat”. Making a conscious effort during the debriefing to include all of the students in a meaningful way can significantly create more learner engagement. Further, if you are running multiple scenarios I believe that engaging all the learners encourages them to pay closer attention if they are in an observation role for subsequent scenarios.

  1. Pull the ideas, don’t push the facts

I like to think of the debriefing as the time when we explore the learners thought processes. If we are transmitting information or pushing facts to them the situation can become more of a lecture. In fact I see many novice debriefers break into song and start delivering a mini lectures during attempts at debriefing. It is important to remember that when you are pushing the facts to the participants it limits the amount of assessment that you can do in terms of their understanding of the material and what you need to do to create deeper learning. So, if you find yourself making many declarative statements, pullback, and start to ask some questions. Encourage critical thinking, self reflection and ensure you are helping to create linkages of what went well during the scenario and why it was good, along with allowing the participants to discover and identify what they should do differently if they were to face a similar situation in real life or another simulation to improve.

  1. Create a summary of the take home points

Novice debriefers tend to struggle with creating an adequate summary. Also, Beware. This is another time that is at risk for the debriefing turning into a mini lecture. It is helpful to have a list of the major take-home points associated with the scenario. You can contextually adapt the summary to the performance that occurred during the simulation scenario even if you have the summary points written out prior to the simulation occurring. It is important to remember that during a debriefing many areas can be covered and touched upon. Learner should be engaged to identify the major learning points that they experience in the simulation, as well as understanding how the simulation was relevant to helping them become better healthcare providers.

So, this was intended to be five random tips on how to improve the effectiveness of your debriefing strategy. I hope that you found them useful!

Now, go forth and do great debriefings extra mission point

 

Until next time,

Happy Simulating!

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February 17, 2017 · 5:32 pm

Patient Centered Debriefing – Putting the Patient First – A MUST for Healthcare Simulation

patientcentereddebiriefingDebriefing in healthcare education is a specific type of communication designed to allow enhanced learning through a post hoc analysis and (ideally) structured conversation of an event. While there are many different styles and methods commonly described for use in healthcare simulations there are generally some consistent principles. Common features of the goals of just about every debriefing method includes attempting to ensure that the participants involved in the event leave with an understanding of areas in which they performed well and areas that they could improve upon should the face a similar situation in the future.

Debriefing is not easy to do well for a variety of reasons, and suffice it to say generally improves with practice and a focus on improvement. Depending on the facilitator and/or the learner(s) many people struggle with ensuring learners depart the debriefing with a clear understanding of areas needed for improvement. Other times debriefers can make the mistake of focusing only on the negative, forgetting to elucidate the things that may have been done well.

I believe we need to always incorporate the needs of the patient into the debriefing. The thought that the simulation benefits the patient should permeate throughout the planning of all events in healthcare simulation including the debriefing.

With the proliferation of simulation based learning over the last two decades there has been an increased interest in faculty development and training of people to develop debriefing skills. Nearly every discussion of faculty training in the simulation healthcare simulation space includes some discussion of the safe learning environment and student-centered learning. These concepts are embedded in nearly every discussion and every publication on debriefing and feedback.

Ostensibly the safe learning environment is referring to a facilitator controlling the environment of simulations and debriefings to provide an environment of comfort that encourages participants to be able to share freely what is on their mind during the simulation and the debriefing without fear of repercussion, ridicule or reprisal. I also believe that it should encourage simulation faculty to remain vigilant for opportunities that need some sort active facilitation to assist a participant thought to be struggling with the situation from either an emotional or perhaps stressful stimulus.

Having been involved in the teaching of healthcare providers for almost thirty years and when thinking backing to the late eighties, I personally participated in early “simulations” designed to “knock students off of their game”. Thus, I can certainly relate to, and applaud the emergence of the concept of a safe-environment.

However, I now believe that the concept of a student-centered approach to healthcare education contributes to the illusion that the student is the ultimate benefactor of healthcare education programs. The concept has evolved because of a natural parenteral feeling of protection for students, along with the fact that experiential learning can be stressful. Balancing these factors can likely contribute to highly effective learning as well as a positive learning experience for the participant.

When applied to healthcare education student-centered learning can be a bit misleading, perhaps a bit irresponsible, in so far that it completely ignores the fact that the patient is the ultimate recipient of the educational efforts. It may be more comfortable for the faculty in the immediate because the student is present and the patient is not. However, if you think about it, down-stream it is likely incomplete and ultimately may do a disservice to both the learners and their patients.

The challenge is that when the pervasive thought process is student-centered, the culture, requisite curriculum and learning opportunity design will favor such a position. This can subtly influence the debriefing and interactions with participants in a way that fails to correct inaccurate or poor performance and/or reinforce decisions or actions that should be carried forward to actual care.

My colleagues and I have coined the term Patient-Centered Debriefing. I originally talked about it on my simulation blog in 2013. In the training of debriefers and the modeling of debriefing, we encourage the consideration of the needs of the patient and these seems to pull to a more appropriate anchor point. This slight shift in focus can also help to humanize the situation beyond the needs of the learner. Taking on the responsibility of eventual care of an actual patient can shift the mindset of the instructor to ensure the real goals of the simulations are met.

What does patient-centered debriefing look like? At casual observation it would appear the same as any other debriefing that is conducted with acceptable methods in 2017 under a premise of student centered debriefing. The difference is the facilitator(s), as well as perhaps the students, would be considering the ultimate patient outcomes associated with the learning objectives of the given scenario. Thus, if properly conducted, facilitator(s) would be less likely to gloss over or omit reconciliation of mistakes and/or errors of commission or omission that occurred during a simulation that would likely contribute to adverse sequela for the patient in a comparable actual healthcare setting. Simultaneously, however the facilitator will be maintaining the enshrined traditional “safe learning environment”.

In considering the needs of the patient there is a subtle reminder that it is our job as healthcare educators to best prepare learners for this reality and the time that we have to do it in is precious.  Further, particularly in simulation based learning it should be an ever present reminder that this is our ultimate purpose. I think it is particularly important for simulation facilitators who are not actively involved in the care of patients to consider this position. This is not to suggest that they are not doing a great job, but it seems like a reasonable active reminder to consider the needs of the patients who will be cared for by the learners involved in the simulation.

I am not suggesting that we abandon the attention to providing a safe learning environment for simulations as well as clinical learning environments. I do believe that this contributes to effective learning particularly in the simulated setting. I do believe that we need to reconsider the concept of student-centered learning insofar as the student being thought of as the epicenter of the overall education process and outcomes.

Reserving the definition and concepts of student centricity for considering the scholarly needs, learning styles, designs and appeals to the intrinsic motivating factors seem more appropriate. Any learning program in healthcare is far better to have a patient-centered axis from which all other actions and designs emerge.

I invite you to consider adopting a patient-centered debriefing into your work!

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August 18, 2015 · 2:56 am

Great Debriefing Should Stimulate Active Reflection

shutterstock_284271476_aDebriefing in simulation as well as after clinical events is a common method of continuing the learning process through helping participants garner insight from their participation in the activity. It is postulated and I believe, part of the power of this “conversation” when call debriefing is when the participant engages in active reflection. The onus is on the debriefer to create an environment where active reflection occurs.

One of the most effective ways to achieve this goal is through questions. When participants are asked questions regarding the activity being debriefed it forces them to replay the scenario or activity in their mind. I find it helpful to begin with rather open-ended broader questions for two reasons. The first is to ensure the participant(s) are ready to proceed. Secondly asking broader questions at the beginning such as “Can you give me a recap of what you just experienced?” Helps to force the participant to think about the activity in a longitudinal way. Gradually the questions become much more specific to allow the participant to understand cause and effect relationships between their performance in the activity and the outcomes of the case.

Another thing to consider is that when debriefing multiple people simultaneously, when a recollection of the activity is being recalled by one participant, the other participants are actively thinking about their own recognition of said activity. Thus active reflection is again triggered. It is quite natural for the other participants to not only be thinking about the activity, but actively forming their own thoughts in a comparison/contrast type of cognitive activity. During this period they are comparing their own recollection of the activity with the one of the person answering the initial question.

Question should be focused in a way that the debriefer is controlling the conversation through a structured pathway that allows the learning objectives to be met. Further, when one develops good debriefing habits through the use of questioning it limits the possibility of the debriefing converting into a ”mini – lecture”.

I believe the Structured and Supported debriefing model created by my colleague Dr. John O’Donnell along with collaborators, provides the best framework by which to structure the debriefing. His use of the GAS mnemonic has effectively allowed the model to be introduced to both novice and expert debriefers alike and facilitate an easily learned structured framework into their debriefing work. We have been able to successfully introduce this model across many cultures and at least five different languages and have had significant success.

Worksheets, or job-aids with some example questions that parallel the learning objectives can be written on such tools prior to the scenario commencement. Supplementing the job aid with additional notes during the performance of the scenario can be helpful to recall the important points of discussion at the time of debriefing, and the preformed questions can serve as gentle reminders to the debriefer on topics that must be covered to achieve a successful learning outcome.

So a challenge to you is the next time you conduct a debriefing be thinking in the back of your mind how can I best force my participants to engage in active reflection of the activity that is bring debriefed. In addition, I would recommend that you practice debriefing as often as you can! Debriefing is an activity that improves over time with experience and deliberate practice.

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June 30, 2014 · 10:22 pm

Feedback – More Than Just Debriefing

EKG_Feedback

Too often in the designs of scenarios for simulation there is a lack of attention to the fact that there are many forms of feedback that occurs during a simulation than the debriefing. Debriefing is certainly an important part of any learning encounter, but in reality represents only one type of feedback.

As you think about sources of feedback I ask you to be both creative and attentive. I like to think of feedback in two broad categories, intrinsic and extrinsic. The latter being the more commonly thought of mechanisms such as debriefings, video reviews, and simulator log file reviews etc. with the former being the topic of this post.

What I find to be of significant interest as it related to the design of scenarios is the feedback that occurs intrinsically. That is clues, or changes that occur during the scenarios that are available to the participant to incorporate in their understanding of how their decisions, treatments, or lack thereof, are affecting the statues of the patient.

Many of you might be saying, what are you talking about???? Ha!!! Now on to my favorite part which is providing concrete examples to help explain myself further.  Let’s say you are simulating a pelvic fracture case with hypotension and shock. The vitals’ of the high technology simulator that you may be using for the case would likely show tachycardia and hypotension etc. Now lets say the participant(s) place a pelvic binding device and give a unit of blood. You may include changes in the vitals appearing on the monitor that indicated that there was mild to moderate improvement of the patient. Perhaps the tachycardia would decrease and the blood pressure may improve over a set period of time.

During the design process of the scenario many people may create the changes in the vitals thinking they are mimicking reality of what may occur.  More importantly I think those involved in the design of the scenario should realize that the changes in the vitals referred to above are a source of important intrinsic feedback. The participants should be able to make the observations and decide they are helping the patient to improve.

This can be powerful feedback that links together successful performance with particular behaviors or decisions that were made. It is self-discovery, it will help to guide further care and decisions if the scenario continues. If the designer of the scenarios recognizes this intrinsic feedback in the design phases, additional creative solutions can be implemented to reinforce the learning.

While my pelvic fracture example shows a positive change tin the patient based on correct actions, the converse example could be true if incorrect care is being rendered. Consider that if you have a heart attack case with hypotension and the patient is administered aspirin and nitroglycerin. You would likely worsen the shock from a physiological perspective. Seeing this change will provide intrinsic feedback to the learners(s).

This is not to say that it all has to do with fancy feedback from high technology simulators. The same could be accomplished with showing a worsening EKG on paper if treatment is incorrect or delayed, or conversely showing and improving EKG for the right treatment given within the appropriate time.

Approaching feedback from a deliberate perspective can be helpful in reinforcing learning. It should be recognized as a design tool and carefully integrated into the core deign of any scenario. Debriefing can be linked to these feedback areas in the scenario. This can provide valuable links or areas ripe for discussion to assist in accomplishing the learning objectives.

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