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The Art and Science of Debriefing. Maria Overstreet, PhD, RN, CCNS. Who Am I?. Nashville Native History: Nurse for 25 years Simulation: just happened into it… Debriefing: Chose to perform research Simulation Consultant: Enjoy doing!. Objectives. Learner will become more knowledgeable of:

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the art and science of debriefing

The Art and Science of Debriefing

Maria Overstreet, PhD, RN, CCNS

who am i
Who Am I?
  • Nashville Native
  • History: Nurse for 25 years
  • Simulation: just happened into it…
  • Debriefing: Chose to perform research
  • Simulation Consultant: Enjoy doing!
objectives
Objectives
  • Learner will become more knowledgeable of:
    • Debriefing in respect to:
      • History
      • Meaning
      • Concepts
      • Methods
      • Application
debriefing
Debriefing
  • Has anyone ever facilitated a simulation debriefing?
  • How do you define Debriefing?
literature of debriefing military
Literature of Debriefing: Military
  • WWII, Army’s chief historian, Brigadier General Marshall
    • Performed 1st Historical Group Debriefing (HGD)
      • Soldiers recounted events of combat, feelings, & decisions
      • Unexpected finding was psychological benefits
        • Termed Spiritual Purging symbolizing cleansing of one’s actions during combat
  • Fillion, Clements, Averill, & Virgil (2002), MacDonald (2003)
literature of debriefing psychology
Literature of Debriefing: Psychology
  • Mitchell (1983) a psychologist
    • Worked with emergency services personnel
    • Developed method of debriefing
      • Critical incident stress debriefing (CISD)
        • Recount events, discuss actions/decisions, discuss feelings
    • Dyregrov (1989) adapted Mitchell’s technique
      • Emphasized process and flexibility
        • Particularly time and routine
psychology
Psychology
  • Red Cross Debriefing of 1989 San Francisco earthquake
  • Found small group size allowed for more intimate exploration of worker’s thoughts & feelings (12-15 for 2 hours).
  • Concurs with Dyregrov 2 factors important:
    • Time & timing
      • Length of time of debriefing
      • Proximity to the event
literature of debriefing education
Literature of Debriefing: Education
  • No works from education literature are evidence based research studies.
  • Provide important theoretical and conceptual information
    • Lederman (1984) differentiates educational debriefing from other debriefings due to emphasis on the learning derived from the experience.
      • Proposed term “postexperience analytic discussion process” (Lederman, 1984, p. 415)
      • Refined term to “cognitive assimilation of experience”
concepts of literature important in debriefing
Concepts of Literature Important in Debriefing
  • Communication
    • Discussion of events: What happened?
    • Language use: words & body
  • Time/Timing
    • Time is a controversial factor
      • How long, who speaks for how long, & role of silence
      • Timing: when to introduce or stimulate a discussion
  • Emotion
    • Attention to the affective domain: feelings & emotions
  • Structure
    • Pattern of organization, how it flows; anticipation of learner of what is to come
research of healthcare debriefing
Research of Healthcare Debriefing
  • Points to VALUE of debriefing
  • Savoldelli, et al (2006)
    • Verbal & verbal + video improved skill performance
  • Jefferies & Rizzolo (2006)
    • Learner identified debriefing as the most important design feature of simulations
    • Learner’s self-confidence ratings increased with active learning followed by reflective exercises
research of healthcare debriefing1
Research of Healthcare Debriefing
  • Lasater (2007)
  • Studied simulation & critical thinking
    • Comments on necessity of assisting students to cope with their emotions following simulation
      • Addresses the affective domain of learning
research of healthcare debriefing2
Research of Healthcare Debriefing
  • Johnson-Russell (2007)
  • Presents a loose structure for debriefing
  • Refers to 4 stages:
    • Introduction
    • Personal reaction [psychological component]
    • Discussion of events [What happened?]
    • Summary [Synthesis of knowledge, meaning making]
theory of experiential learning
Theory of Experiential Learning
  • Dewey (1938)
  • Learning by doing
  • Not every experience results in education or learning
  • LEARNER must:
    • Interact with environment
    • Make meaning of the experience from past, present, or future
theory of experiential learning1
Theory of Experiential Learning
  • Debriefing by Dewey’s theory of experiential learning…
  • Reflective component
    • Provides opportunity to link knowledge and experience or knowledge, skill, and meaning derived by the learner
theory of experiential learning2
Theory of Experiential Learning
  • Kolb (1984)
  • Experiential learning model
  • Represents 4 cyclic stages learners venture through to understand experiences
  • Reflective Observation
    • Discuss experience, ponders what went well & not, seeks affirmation or learns alternative method, gains insight
theory of experiential learning3
Theory of Experiential Learning
  • Schön (1987)
  • Learning through reflecting as it relates to practice professions
  • Isolated reflection & expanded on its meaning
    • 2 methods of reflection in practice:
      • Reflection in action (thinking while performing)
      • Reflection on action (pose ? To self to change)
research of nursing clinical simulation debriefing
Research of Nursing Clinical Simulation Debriefing
  • Overstreet (2009)
  • Qualitative study
  • Case study design (4 independent cases)
  • Data
    • Observation & field notes
    • Video of debriefings
    • Facilitator interview
    • Facilitator questionnaire
    • Student questionnaire
overstreet s research findings
Overstreet’s Research Findings
  • Original 4 concepts from literature emerged
    • Communication
    • Time/Timing
    • Structure
    • Emotion
additional patterns emerged
Additional Patterns Emerged
  • Triangulation of data sources: from both students and facilitators
    • Accentuate the positive
    • Higher Order Thinking
    • Experience Counts
methodology design
Methodology & Design
  • Qualitative Research
      • Explore phenomenon through identifying idiosyncratic patterns of behaviors
      • When little is known
        • Madjar & Walton, 2001
  • Case Study
      • Investigate a contemporary phenomenon within its real-life context
      • Multiple sources of data
        • Yin, 2003
focal points
Focal Points
  • Teacher
      • Student
        • interaction
  • Process
      • time spent in certain aspects of exchange
  • Content
      • what is communicated
actual research
Actual Research
  • IRB Approval
  • Protocol remained same for each data collection
    • Observe
    • Videotape
    • Student Questionnaire
    • Educator Semi-structured Interview
    • Educator Questionnaire
    • Field Notes
case study analysis of data
Case Study Analysis of Data
  • Triangulation of multiple data sources
  • Categorical aggregation
  • Time-ordered analysis
  • Pattern matching
  • Cross-case synthesis
case 1 using storytelling
Case 1: Using Storytelling
  • Pre-simulation – 30
  • Simulation – 30
  • Debriefing – 25
  • Content – Med/surg
  • Students – 6 (22 yr old)
    • AD, (1 AA, 5 Cau, 1♂)
  • Educator – Cau, ♀
    • 23 yr RN, used personal storytelling for emphasis
    • Tone - Natural
case 2 the therapeutic milieu
Case 2: The Therapeutic Milieu
  • Pre-simulation – 5
  • Simulation – 105
  • Debriefing – 47
  • Content – Skill practice
    • Communication w/pt.
  • Students – 7 (22 yr old)
    • BSN, (1AA, 6 Cau, all ♀)
  • Educator – 2, Cau, ♀
    • 14 & 4 yrs RN
    • Structured, safe & trusting atmosphere
case 3 the critical critical care nurse
Case 3: The Critical, Critical Care Nurse
  • Pre-simulation – 5
  • Simulation – 50
  • Debriefing – 28
  • Content – Cardiac/ED
    • Decisions at point of care
  • Students – 3 (38 yr old)
    • BSN, (All Cau, 1 ♂, previous roles)
  • Educator – 2, Cau, ♀
    • 18/10 yr RN
    • Feedback(-),(93 ?/20min)
case 4 preparing for the future
Case 4: Preparing for The Future
  • Pre-simulation – 5
  • Simulation – 90
  • Debriefing – 38
  • Content-Sepsis/ED/ICU
    • Decisions at point of care
  • Student – 7 (22 yr old)
    • BSN, 1 AA, 1 ♂
  • Educator - ♀ Cau.
    • 38 yr RN/34 yr teaching
    • Interweave of emotion
patterns
Patterns
  • Structure
    • All 4 heavy in structure, physical environment
      • Case 1: driven by written questions
      • Case 2: (+) peer feedback
      • Case 3: knowledge questions
      • Case 4: less defined: variety of teaching methods
  • Communication
    • Listening: to hear with thoughtful attention
    • Language: words, pronunciation, includes tone and body
    • Pattern frequencies: links, swoops, timing
    • Case 4 – swoop 8 times / Case 2 – no swoops in analysis
patterns1
Patterns
  • Time
    • Time spent in debriefing – 25-47 min.
    • Educator talk time 18 – 30 min.
    • Silence 0 – 5 min.
    • Case 2: Outlier student talk time
    • Case 3: Students answered 57 X in 2.5 min(2.6 sec/answer)
  • Emotion
    • Case 1 & 4: Storytelling and interweave of emotion
    • Case 3: Negative vs positive feedback (18/9/5)
      • “I was thinking their knowledge base was a little more than what it may have been”
new patterns emerged
New Patterns Emerged
  • Accentuate the Positive
  • Higher Order Thinking
  • Experience Counts
accentuate the positive
Accentuate the Positive
  • Educators unanimously perceived students & themselves (+)
    • “I try to end it in a positive by asking the students a couple of things they learned today that they didn’t know before…”
    • “Cause we want them to leave feeling positive about simulation and not being terrified and being embarrassed cause we are using simulation in every single course”
  • Students: What did today’s debriefing mean?
    • “It was feedback I needed to hear. It helps me identify + and -.”
    • “to discuss people’s strengths and areas that need to be worked on in a positive manner”
higher order thinking
Higher Order Thinking
  • Putting It All Together
    • Meaning making: Students
      • “Debriefing just put all the pieces of the puzzle together”
      • “Debriefing helped to pull everything together & make sense of it all”
    • Meaning making: Educators
      • Case 1: predetermined goal to connect theory & practice
      • Case 2: tie together student improvement
      • Case 3: tried to tie together knowledge from simulation
      • Case 4: cannot refrain from teachable moment
higher order thinking1
Higher Order Thinking
  • Decision Making and Critical Thinking
  • Case 1 & 3: Dialogue about how decisions were made
  • Case 3: “You get to find out more about what they were thinking…”
  • Case 2: Skill focused: therapeutic communication process
  • Case 4: minimal skill focus, knowledge questions to ponder, overlaid with attention to attitude
  • Students: “Helps you learn & think critically” “to focus on your patient & not the monitors. Also it is important to think critically & prioritize your care”
experience counts
Experience Counts
  • Educators brought themselves to debriefing
  • More experienced vs. less experienced
  • Students value experience
    • “We practiced on a plastic dummy which just increased our chances of responding appropriately to the situation in real life”
so what
So What?
  • Theory
    • Dewey, Kolb, Schön
  • Literature
    • Military, Psychology, Education
  • Concepts
    • Communication, Time/Timing, Structure, Emotion
  • Research Patterns
    • Accentuate +, higher order thinking, experience counts
gathered more knowledge
Gathered More Knowledge
  • Information to consider as you develop your own style of debriefing
  • Ask yourself the question
    • How will I address these concepts in debriefing?
consider objectives
Consider Objectives
  • Objectives for simulation add depth to debriefing
  • Are you going to allow the objectives for the simulation to guide the debriefing, structure the debriefing, limit the debriefing…
how do objectives for simulation guide debriefing
How do objectives for simulation guide debriefing?
  • View code simulation
  • What is the objective for the simulation?
    • 1.) to feel the urgency of being involved in a code situation?
    • 2.) to administer accurate CPR?
how much time
How much time?
  • Will you be very rigid with time
  • Will you be lax with time
  • Literature points to time as important:
    • How long? … As long as the experiential learning
    • For true reflection – have to spend silent time thinking
how do i communicate
How do I communicate?
  • Video tape yourself…you will learn a lot!
  • Language is a powerful tool.
  • Example: [ + / Δ ]
  • How do you communicate this to the learner?
  • What was good/bad?
  • What was done well/what can be improved?
  • How do you list these items?
    • Include the learner in coming up with the items
communicate your findings
Communicate Your Findings
  • Theory
    • Your theory
  • Literature
    • What literature you produce
  • Concepts
    • Concepts you discover in your practice or observe in other’s practice
  • Research Patterns
    • Patterns you produce or you observe
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