Tag Archives: instructor training

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


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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Faculty Development is One of the Keys to Success in Simulation


The number of brand-new shiny, technologically advanced simulation centers popping up around the world is astounding. It is certainly a growing testament to the importance, adoption and recognition of the power the simulation-based education brings to the world of healthcare safety and quality.

What is equally perplexing to me is the amount of meetings, person-hours, drawings, fees paid to architects etc. that it takes to plan a simulation center. People will toil in the detail for thousands of hours to ensure that they buy the biggest, best and most capable simulator, AV equipment and one-way mirrors, color of the floor tiles for the entrance, but don’t put a similar investment of time and money and faculty development. I think there are a number of contributing factors that contribute to this MISTAKE.

Substantial sums of money to put into the bricks, mortar and equipment that goes into simulation centers. Decision-makers are mistakenly led to believe that the equipment environment will do the teaching for them. While there are some intelligent tutoring systems and many technologically advanced simulators that help educators make efficient and effective use of simulation, there still is a dependency upon the educator.

Another common error that I see program make in the design of simulation-based programs is assumptions that people that are already functioning in the role of educators will do just fine transitioning to that in the simulation world. The fact of the matter is simulation-based education/facilitation is a learned and practice skill set that has various components to it that include understanding the psychology of simulation, the technical capabilities of simulation as well the limitations, being artful with facilitation, and forever attentive to the educational objectives that are trying to be achieved through the use of simulation.

I have seen plenty of examples of educators who are great behind a podium doing fabulous lectures and creating great learning experiences that are rendered ineffective when they attempt to facilitate a simulation or conduct a set debriefing session associated with or during a simulation.

Many simulation programs fail at or are slow to achieve their stated aims because they rely on inexperienced facilitation, or educational leaders not familiar with effective and efficient simulation-based education principles. Additionally, the diversity of approaches to simulation leads some to the false assumption that formal training in preparation, practice and demonstration of ongoing skills is unnecessary. This could not be further from the truth, and unfortunately becomes a barrier to many centers.

The road to securing funding for any education based effort in healthcare is a long and arduous path. There is a general ability to generate the funds to buy equipment, renovate and build buildings for simulation based activities. The way of the future is to also introduce during the foundational funding efforts that investment in the people skills is necessary.  A planned pathway of development for simulation-based specific competencies must be planned to help a center achieve and/or surpass its goals.

So if you’re in the planning phases of a simulation-based program or in the position to try to increase the efficiency or effectiveness of your simulation-based program, be sure to seek out professional development activities, formalized instruction, preparation and certification for your simulation-based educators. I think that this will help create synergy within your center and prepare you for success in the execution of the simulation activities that you may already engage in, and will prepare you for the future than increase in the efficacy and efficiency of simulation-based education.

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