Tag Archives: feedback

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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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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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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