Debriefing Methods for Simulation in Healthcare: A Systematic Review

The expository phase of debriefing in clinical simulation: a qualitative study

BACKGROUND

Clinical simulation fosters reflective, experiential learning in a safe environment, allowing participants to learn from mistakes without patient risk. Debriefing, essential for reflection, is typically facilitator driven. The MAES© methodology (Self-Learning Methodology in Simulated Environments) shifts the focus to students, guiding them through six sequential phases: group identity creation, topic selection, objective setting, competency establishment, scenario design, simulation, and debriefing. MAES© introduces an expository phase in debriefing, where students present theoretical and practical content. The facilitator assumes a significant, yet secondary role, fostering increased student-led learning opportunities and, at times, enabling even trained real patients to co-facilitate the debriefing.

OBJECTIVE

To explore participants' experiences and perceptions regarding the expository phase of debriefing within the MAES© methodology framework, with specific focus on the student-led debriefing component.

METHOD

A descriptive qualitative inductive approach with thematic content analysis was used. Open-ended questionnaires from 151 undergraduate final year and post-graduate nursing students, captured their experiences with the MAES© expository phase. Open-ended questionnaires allow participants to freely and anonymously express their perspectives and experiences. Responses were transcribed, independently coded, and analyzed using MaxQDA® v18. Data were coded and analyzed based on absolute and relative frequencies of emerging categories. The study adhered to the SRQR (Standards for Reporting Qualitative Research) guidelines.

RESULTS

The analysis revealed several key themes in student evaluations. Satisfaction with the methodology emerged strongly, with over one-third of participants expressing no desired changes. The reflective nature of the approach was prominently valued, along with its effectiveness for concept clarification and fostering collaborative learning. Participants particularly noted developmental outcomes in communication competencies and technical skills, while appreciating the motivational learning environment and evidence-based focus. The suggested improvements focused on three main aspects: increased session dynamism, a greater use of visual and interactive elements, and reduced dependence on slide-based presentations.

CONCLUSION

The study highlights the value of the expository phase in the MAES© methodology, emphasizing its effectiveness in clarifying concepts, fostering collaboration, and developing technical and communication skills. It also promotes student autonomy through active engagement. However, participants suggested improvements, such as greater dynamism, personalization, and varied presentation methods using videos, skill stations or patient's-oriented debriefing. Overall, the expository phase proves to be a valuable pedagogical tool with potential for broader application in simulation-based learning and other debriefing models.

CLINICAL TRIAL NUMBER

Not applicable.

Evaluating the use of BodyWorks Eve® high-fidelity ultrasound simulation equipment in formative clinical assessments

Introduction

Increasing demand for ultrasound services is reducing learners' access to medical ultrasound clinical experience. High-fidelity simulation equipment, such as the BodyWorks Eve®, enhances the learners' experience and scanning ability. This has the potential to improve patient safety as the learners' ability to detect, identify and accurately report a known pathology can be assessed, which is not possible in clinical practice.

Methods

Participants performed one pathological ultrasound examination on the BodyWorks Eve® and the participants' performance level was assessed by the primary investigator using a formative clinical assessment form already used by the Diagnostic Imaging programme at the University of Leeds. The outcome was analysed using narrative statistics, and participants' feedback was evaluated using thematic analysis.

Results

A total of 16 participants were recruited. Eight (50%) reached the required level, but eight (50%) failed to reach the required level in at least one of the seven criteria that indicate professionally incompetent or dangerous practice. Thematic analysis of all the participants' comments identified four main themes and two sub-themes which highlighted the benefits of the simulated assessment for prompting reflection, replicating clinical practice and gaining confidence in the assessment process, while also identifying negative aspects such as technical limitations when using the BodyWorks Eve®.

Conclusion

Most participants evaluated the BodyWorks Eve® favourably. Using BodyWorks Eve® for formative clinical assessments is feasible and acceptable to participants. Further correlation to outcomes in clinical practice would be useful.

Exploring the role of self-led debriefings within simulation-based education: time to challenge the status quo?

BACKGROUND

The notion that debriefing quality is highly reliant on the skills and expertise of the facilitator is being increasingly challenged. There is therefore emerging interest in self-led debriefings (SLDs), whereby following a simulated learning event, individuals or groups of learners conduct a debriefing amongst themselves, without the immediate presence of a trained facilitator. The interest in this approach to debriefing is multifactorial but is, in part, driven by a desire to reduce costs associated with resource-intensive faculty presence. The debate regarding the role of SLDs in simulation-based education (SBE) therefore has important implications for the simulation community.

MAIN BODY

We comprehensively explore the role of SLDs by contextualising their application across the spectrum of SBE, both in terms of contrasting simulation factors, namely (i) simulation modality, (ii) debriefing forum, and (iii) debriefing adjuncts, as well as different learner characteristics, namely (i) learners' previous simulation experience, (ii) learner numbers, and (iii) learners' professional and cultural backgrounds. These factors inherently shape the conduct and format of SLDs, and thus impact their effectiveness in influencing learning. We have synthesised and critically analysed the available literature to illuminate this discussion.

CONCLUSIONS

The current evidence suggests that SLDs can, in the right circumstances, form part of an effective debriefing strategy and support learners to reach appropriate levels of critical self-reflection and learning. Careful consideration and due diligence must go into the design and implementation of SLDs to augment the advantages of this debriefing format, such as enhancing flexibility and learner autonomy, whilst mitigating potential risks, such as reinforcing errors and biases or causing psychological harm. In situations where resources for facilitator-led debriefings (FLDs) are limited, simulation educators should recognise SLDs as a potential avenue to explore in their local contexts. By leveraging the strengths of both formats, balancing learner autonomy and expert guidance, a combined SLD and FLD approach may yet prove to be the optimal debriefing strategy to maximise learning. Whilst more research is needed to deepen our understanding of the nuances of SLDs to assess their true applicability across the spectrum of SBE, the time may now have arrived to consider challenging the status quo.

Teach the Unteachable with a Virtual Reality (VR) Brain Death Scenario - 800 Students and 3 Years of Experience

Introduction

Traditionally, clinical education has combined classroom theory with hospital-based practical experiences. Over the past 50 years, simulation-based training, particularly virtual reality (VR), has gained prominence for its flexibility and scalability. This article describes the development, implementation and evaluation of a VR-based brain death diagnostic training module at the University of Münster over a three-year period.

Methods

A multidisciplinary team developed the VR scenario to simulate a realistic intensive care unit, in line with German guidelines for brain death diagnosis. The module includes a tutorial and a preparatory video podcast to accommodate varying levels of VR experience. The course maintained its former small-group format, integrating VR to replace a manikin-based brain death examination. A randomized pilot study compared the traditional and VR-based approaches.

Results

Feedback from over 800 students indicated a strong preference for VR training, with a significant increase in perceived competence in brain death diagnosis. The VR module also increased the individual training time and provided more varied clinical scenarios than traditional methods. Continuous feedback led to iterative improvements, including reflex simulations and improved hardware management.

Discussion

The VR-based training was well received, demonstrating its potential to revolutionize medical education by providing immersive, realistic simulations. Challenges such as initial hardware adaptation and high personnel costs were addressed through comprehensive tutorials and structural adjustments. The success of this module has led to the development of additional VR courses, optimizing the use of hardware and justifying the initial investment.

Conclusion

The integration of VR into medical education at the University of Münster has proven effective, enhancing student engagement and competence in brain death diagnosis. The positive outcomes suggest a promising future for VR in medical education, highlighting the importance of innovative tools in the preparation of future medical professionals. Efforts are continuing to broaden the application and accessibility of VR-based training.

Localizing and Tailoring the Debriefing Assessment for Simulation in Healthcare to Optimize Fit

Introduction Debriefing in healthcare simulation is helpful in reinforcing learning objectives, closing performance gaps, and improving future practice and patient care. The Debriefing Assessment for Simulation in Healthcare (DASH) is a validated tool. However, localized rater training for the DASH has not been described. We sought to augment DASH anchors with localized notations, localize DASH rater training, assess localized DASH correlation with other debriefing practices/factors, and assess reliability of the localized tool. Methods This study was conducted at SimTiki Simulation Center, John A. Burns School of Medicine, University of Hawai'i at Mānoa. Three simulation experts without DASH training developed a list of debriefing best practices/factors, reviewed the DASH handbook, and transcribed the DASH Rater Long Form version with example behaviors into a rating document. Research assistants recorded best practices/factor data from archived debriefing videos. Simulation experts independently scored debriefings, resolved discrepancies and added localized criteria to the DASH. Rater calibration was completed with an intraclass correlation (ICC) of 0.884. Raters then independently scored 43 debriefings recorded during July-December 2022. DASH scores were compared to observed debriefing best practices/factors. Results The overall DASH behaviors ICC agreement was 0.810 and consistency was 0.825. Behavior scores ranged from 2.45 (SD 0.70) to 4.42 (SD 0.81). The three lowest scoring DASH behaviors were 2A (2.45), 4A (3.41), and 3B (3.44). In behavior 2B regarding realism concerns, there was significant inconsistency in the use of the not applicable (NA) designation. DASH and best practices/factors construct correlation supported convergent validity. Conclusion High interrater reliability followed localized rater training and the addition of localized notations to DASH. Correlation with debriefing practices/factors strengthens DASH validity evidence. Lower DASH behavior scores reported generally suggest that the interpretation of DASH scores is best contextualized in a shared localized DASH construct. A comparison of DASH numerical scores between institutions, with different raters, and different cultures may not reflect absolute debriefing quality.

Exploring the Meta-debrief: Developing a Toolbox for Debriefing the Debrief

SUMMARY STATEMENT

Otherwise known as debriefing the debrief, meta-debriefing describes the practice of debriefing simulation facilitators after they have facilitated, or observed, a debriefing. It is a vital component of enhancing debriefing skills, irrespective of where debriefers may be in terms of their professional development journey from novice to expert. We present the following 4 fundamental pillars, which underpin the creation of an impactful meta-debriefing strategy: theoretically driven, psychologically safe, context dependent, and formative in function. Furthermore, we describe various strategies that, underpinned by these 4 key pillars, contribute to a toolbox of techniques that enable meta-debriefers to develop proficiency and flexibility in their practice. We have synthesized and critically reviewed the current evidence base, derived mostly from the debriefing literature, and highlighted gaps to address in meta-debriefing contexts. We hope this article stimulates discussion among simulation practitioners, progresses the science and art of meta-debriefing, and prompts further research so that meta-debriefing can become an integral evidence-based component of our faculty development processes.

Speech recognition technology for assessing team debriefing communication and interaction patterns: An algorithmic toolkit for healthcare simulation educators

BACKGROUND

Debriefings are central to effective learning in simulation-based medical education. However, educators often face challenges when conducting debriefings, which are further compounded by the lack of empirically derived knowledge on optimal debriefing processes. The goal of this study was to explore the technical feasibility of audio-based speaker diarization for automatically, objectively, and reliably measuring debriefing interaction patterns among debriefers and participants. Additionally, it aimed to investigate the ability to automatically create statistical analyses and visualizations, such as sociograms, solely from the audio recordings of debriefings among debriefers and participants.

METHODS

We used a microphone to record the audio of debriefings conducted during simulation-based team training with third-year medical students. The debriefings were led by two healthcare simulation instructors. We processed the recorded audio file using speaker diarization machine learning algorithms and validated the results manually to showcase its accuracy. We selected two debriefings to compare the speaker diarization results between different sessions, aiming to demonstrate similarities and differences in interaction patterns.

RESULTS

Ten debriefings were analyzed, each lasting about 30 min. After data processing, the recorded data enabled speaker diarization, which in turn facilitated the automatic creation of visualized interaction patterns, such as sociograms. The findings and data visualizations demonstrated the technical feasibility of implementing audio-based visualizations of interaction patterns, with an average accuracy of 97.78%.We further analyzed two different debriefing cases to uncover similarities and differences between the sessions. By quantifying the response rate from participants, we were able to determine and quantify the level of interaction patterns triggered by instructors in each debriefing session. In one session, the debriefers triggered 28% of the feedback from students, while in the other session, this percentage increased to 36%.

CONCLUSION

Our results indicate that speaker diarization technology can be applied accurately and automatically to provide visualizations of debriefing interactions. This application can be beneficial for the development of simulation educator faculty. These visualizations can support instructors in facilitating and assessing debriefing sessions, ultimately enhancing learning outcomes in simulation-based healthcare education.

How to deliver effective paediatric simulation based education

Simulation based education (SBE) is an educational tool increasingly used in the approach to the initial and ongoing education of healthcare professionals. Like all education tools, SBE needs to be used appropriately to achieve the desired outcomes. Using Cognitive Load Theory (CLT) in the instructional design of simulations is essential to maximise participant learning by reducing extraneous load and optimising intrinsic load. Educators can modify task fidelity, task complexity and instructional support to optimise learning. Specific methodologies can be used in program design such as rapid cycle deliberate practice, round the table teaching, low dose high frequency and flipped classroom. Fidelity and authenticity are important factors to consider when choosing design elements to ensure learner engagement, but not to overwhelm cognitive load. An integral part of SBE is the feedback or debriefing component. Several evidence-based methodologies can be employed to facilitate post simulation learning, including Debriefing with Good Judgement and PEARLS. Educators also need to consider faculty education and development, such as the discovery, growth and maturity model.

Obstetrics and Gynecology Hospitalists as Champions of Drills and Simulation

Obstetrics and gynecology Hospitalists are not only skilled providers of emergency obstetric and gynecologic care but also safety officers who advocate for and maintain safety and quality in the hospital setting. In these areas and others, they play an essential role in championing and establishing simulation-based education in the hospital setting. The use of Simulations and Drills in maintaining quality and safety in patient care is nationally recognized by leading obstetric and gynecologic organizations.

Use of different debriefing methods after in situ simulation with intensive care unit nurses

BACKGROUND

The debriefing phase is the simulation phase where performance improves and learning occurs.

AIM

This study examined the effects of the learning conversation (LC)-based, 3D (defusing, discovering and deepening) model-based and unstructured debriefing methods on satisfaction and debriefing experience after in-situ simulation among intensive care unit (ICU) nurses.

STUDY DESIGN

In this randomized controlled experimental study, three debriefing methods were compared, according to which 119 ICU nurses were divided into the following groups: LC group (n = 38), 3D group (n = 40) and control group (n = 41). In- situ simulation was performed with an intensive care patient scenario. p < .05 was considered statistically significant.

RESULTS

The total Debriefing Experience Scale-Experience with Debriefing part scores were 89.76 ± 8.10 in the LC group, 88.90 ± 8.70 in the 3D group and 88.29 ± 7.28 in the control group. No significant difference was found in debriefing experience and satisfaction between the groups (p > .05), but a significant difference was observed in the LC group. The groups showed a homogeneous distribution regarding participant characteristics.

CONCLUSION

Debriefing experience and satisfaction do not differ between the methods.

RELEVANCE TO CLINICAL PRACTICE

Implementation of the simulation in the ICU in - situ with ICU nurses is beneficial in obtaining a fidelity experience. Performing the debriefing application after simulation in line with the model supports the International Nursing Association for Clinical Simulation and Learning (INACSL) debriefing standards.