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Feedback – More Than Just Debriefing


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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Assess-a-Phobia In Simulation – What Do We Tell the Patients?

shutterstock_119870338We need to end the terror at the thought of using simulation for assessment. I am of the opinion that one of many significant returns on investment to the healthcare community for simulation is in our ability to develop tools to help objectively assess performance. Healthcare education has evolved with a strong reliance on the knowledge base test, those that assess one’s cognitive knowledge. There is little doubt that no matter what profession in healthcare one practices a high degree of cognitive knowledge and intellectual competence are both necessary.

However, in healthcare it is important that one can apply the knowledge given the contextual circumstances they are faced to deal with when caring for patients.  Simulation is evolving as an excellent tool to help provide some insight into one’s performance competence. In other words it gives us another vantage point to understand if one can actually practice and put into good use the intellectual capital that resides in their brain that was acquired through various methods of educ ation as well as experience.

Having been an educator for well over 25 years I have conducted my share of assessments. Admittedly, most of them are cognitive tests, i.e. written tests to do some sort of knowledge base shutterstock_89679427assessment. In fact, I bet most people reading this have developed some sort of written test assessment that they have given to students sometime in their career as an educator. We think nothing of creating a written test, dealing it out to a room full of students and assessing them on their ability to pass the test by whatever bar we have set as a passing score. Typically a written test has many, many items to account for the fact that variability in the testing process, variability in the interpretation of a question, as well as the fact that one not knowing a single fact should not contribute to a pass or fail on its own.

Depending on the level of stakes of the exam, we will apply more and less rigor in trying to statistically validate each item, or the test overall. Over time we become confident in our written testing instruments and use them over and over again. Eventually, we develop the confidence to say someone actually passes or fails. This can be high-stakes such as passing or failing a course, passing or failing an examination of competence that may lead to certification or other such examples.

I believe some aspects of simulation have evolved to be just as good as that bubble sheet in one’s assessment. In fact I suppose that’s not even a fair comparison because the bubble sheet is going to assess something different than the simulation. Why of course there might be overlap in what we are assessing with these two instruments but they are different tools indeed. The bubble sheet is going to best be assessing cognitive knowledge, and the simulation can be engineered to assess application of knowledge into practice.

shutterstock_85476502There is a reluctance amongst many to engage in simulation assessment activities and I am not sure why. If we think about the analogy to the written test I described above, we feel really comfortable going into a room by our self or with several of our colleagues in creating a multiple-choice written test. Why is it that we cannot go into a room with a number of our colleagues and develop some sort of assessment for simulation environment and capitalize on the advantage of the ability to observe one’s application of knowledge as described above? Continuing with the same analogy, we can then collect data over time and compare the individual items that were assessed, or the ability of the test as a whole for validity.

The origin of this reluctance is complex. In fact, the whole notion of performance assessment of humans is quite complex. However, we should not run from things because they’re complex. I think another part of the reluctance is it is a challenge to our own comfort zone. Arguably it is more difficult to give direct feedback and let someone know that they did something incorrectly, unsafe or otherwise in a face-to-face discussion as compared to letting them go to the wall where their grades are posted and see that they failed the written exam. Another piece is it takes a lot of work to design such assessment tools. But again, the mission is so critically important can’t run from the hard work.

Another part of the reluctance comes in the fact that very few of us were actually trained in the creation of human performance examinations. However if you think that through, very few of us were formally trained in the science of creating written test examinations either. Yet the comfort factor with the latter allows it to happen much more routinely.

Another way to think about it is, if you are a clinician that is supervising a trainee doing a potentially dangerous procedure on a patient is your job to give them feedback that will allow them to improve in the future. Likely some of this conversation will be reinforcing the things that were done appropriately while other aspects of the conversation will require them to make changes for the future for the things that they did improperly. So in essence, you have created an assessment!

Some will read this and argue that assessment violates the principles of a safe learning environment. I fall back on the topic of one of my previous posts, and say that we need to concentrate on Patient Centered Simulation. Likely those who argue that point are not on the front lines of healthcare and understand the need for near-perfect performance in everything we do as we do things for and to patients. Nothing is quite as disconcerting as seeing a trainee make a mistake on actual patient that has a high potential, or actually causes harm. Do we then turn to the patient or the family and say, “I’m sorry, we had the ability to assess their competency in the placement of a central line, but we thought we shouldn’t do that because it wouldn’t represent a safe learning environment.”? Seriously? I think not!!!!!

Simulation has what is so far a largely untapped capacity and capability to assist us in the journey that will make an assessment pathway to help assess competence in the newly acquired skills and critical thought process, as well as evaluation of the maintenance of proficiency and currency of knowledge, as well as application of knowledge over time.

I truly believe that it is the assessment component that will help bring the demands of simulation to the next level. It can be an important tool in the migration from time-based objectives, to a more rational system of performance-based objectives when considering things such as acquisition of practice competence, advancement in training, or even the measurement of competency in the maintenance of practice over time.

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Suspension of Disbelief is So Yesterday – Lets Think About a Great Movie Encounter

The concept of “suspension of disbelief” was orginally attirubuted to a poet/philospher in the 1800’s with regard to creating works of fiction to be interpreted by readers. When I first started in healthcare simulation back in 1997 it was told to me that we needed to create an environment where there is a suspension ofdisbelief so that the participants will believe that they are in the actual health care environment and perform accordingly. I drank the coolaid, I thought that is what we were to do. Today when I reflect on this notion it seems a bit crazy when it is inerpreted to mean that we are designing simulations to make participants forget they are in the simulated environment.

Certainly we don’t want health care professionals to actually think they are in the real clinical environment when they engage in simulation.  We want to create an evironment where they can perform aspects of what they do when they are taking care of real patients so that we can form an opinion to help them improve. This ocurrs through feedback,  assessment and debriefing methods as well as other innovative learning and assessment strategies.  I think we need to think of it more as a “fiction contract” which I believe was a term coined by Peter Dieckmann of Copenhagen which has always resonated with me. (At least he was the first person i heard use it in that concept, shutterstock_130674926and he a brilliant mind in simulation as well as a friend.  So barring any information to the contrary, i’ll leave it attributed to him for the time being 🙂 )

A good metaphor would be to think of it more like the intellectual engagement of going to see a great movie. The movie goer buys a ticket and enters into a contract (of sorts) with the producers of the film and perhaps the movie theater involving a belief  that the money they are spending will allow them to see something that is not quite real, but is a reenactment of something real, and  perhaps they will be participating in it emotionally and psycologically, but they never thought it was real.  However, the value to the participant is in the movie metaphor would be the entertainment provision.  So in essence the “deal” is summarized by the fact that they are entering into an unofficial agreement that says I will provide you $15 to buy the movie ticket, and you will provide me two hours of entertainment. 

I think there are strong analogies between that and the way we should approach healthcare simulation relationship between participants and the simulation providers. We need to create environments where the participants trust us so that they will engage psycologically and emotionally in the simulated environment  in exchange for the valuable use of their time to help them improve as a healthcare provider. 

I think that if we shift the focus so that we are not trying to create a “suspension of disbelief”, it will allow us to better create the environment necessary for effective healthcare simulation. That is that we realize we’re not trying to recreate everything to do with reality in healthcare, we’re just trying to recreate that which allows the participant to engage in a way that they might when they are actually taking care of patients. I think it is particularly important to be direct in letting the participant know that not everything we do in simulation will mimic their realistic practice environment. If we are honest with this orientation and apporach, I believe it causes less constrenation on the part of the participant who is in an environment where some things seem real and some things do not.

Participants are often experiencing a sense of  internal “conflict” when interpreting what the see, hear and experience in the simulation, wondering is this supposed to be part of the simulation or not? I am of the opinion that they are more likely to reconcile this with us if we are frank, open and honest about the intent and expectations of the simulation. This is in contrast to simply asking them to “pretend this is all real” conceptually describing the mantra of suspension of disbelief.

Through this bilateral agreement we enter into a fiction contract or a trust contract that says, on the participant’s side, I will engage in this activity in exchage for the trust that you are making valuable use of my time and helping me become a better healthcare professional.  On the simulation provider side of the agreement it goes something like this: “we will create an educational program using aspects of simulation, which some parts will feel realistic and some will not, but we commit to you that this will be a valuable use of your time with tust, dignity, respect and professionalism. We will attempt to help you get better as a healthcare provider.”  Isn’t that what we’re all trying to accomplish? To me this seems more plausible than asking professionals to suspend the disbelief and interpret the entire simulation as “real”………

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Simulation and the Future of Customized Continuing Education for Practicing Professionals

Click Here to Watch the Video on YouTube

I posted a new video on the WISER You Tube channel describing how simulation can fit into a futuristic model of customizing a pathway of continuing education for practicing healthcare professionals. The model incorporates the utilization of healthcare system quality, safety and risk data. A provocative thought to move us down a road to help imoprove replace the time honored, yet inefficient system of continuing education that exists currently.


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November 13, 2013 · 7:50 pm

Patient Centered Debriefing – The Ultimate Goal

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.



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