Nursing Education and Designing Simulations, Simulation Model, Evidence Based Debriefing and Reflection for Simulation Use
Designing Simulations for Clinical Learning Environment In Nursing Education
Simulations should be carefully planned. The process of designing, implementing, and evaluating a simulation to support learning in nursing education is best done using a systematic, organized approach.
To help nursing educators and researchers in this developmental process, a simulation framework (Jeffries, 2005) has been developed to identify the components of the process and their relationship to guide the design, implementation, and evaluation of these activities.
Simulation Model for Clinical Learning Environment In Nursing Education
A framework has been designed by a national group organized by the National League for Nursing to assist educators in outlining the first steps of simulation development to provide a consistent and empirically supported model to guide the design and implementation of simulations as well as the assessment of learning outcomes when using simulations (Jeffries, 2005, 2012). Within the framework, five design features for developing a clinical simulation scenario are described..
When developing the scenario, the design features are considered within the development process. For example, problem-solving components are considered in the scenario progression writing.
Faculty can consider one or two problem-solving components designed in the scenario to be implemented by the novice students and three or four decision-making components for the more advanced student, perhaps to facilitate and emphasize prioritization at this level.
After the simulation template is completed, it is advised that the scenarios be peer reviewed by content experts to ensure that evidence based practices are being incorporated into the scenario and to confirm accuracy and that the content is up to date for today’s healthcare world.
Finally, the scenario must be pilot-tested with targeted end users so that educators can ensure that the scenario is at the correct level for the learner and can review the scenario for sufficient decision making points and cues to engage the students in the simulation.
A variety of resources exist to provide educators with knowledge and skills on developing simulation scenarios, including regional and national workshops, conferences, instructor courses, and several publications (Campbell & Daley, 2008; Guhde, 2011; Jeffries, 2007; Simulation Innovation Resource Center [SIRC], n.d.).
Evidence Based Debriefing and Reflection for Simulation Use In Nursing Education
Debriefing is one of the key design features to consider when developing a simulation. Debriefing is a process by which educators facilitate learners’ reflection or reexamination of clinical encounters (Dreifuerst, 2009, 2012). Ideally, debriefing should be twice as long as the scenario and involves active participation from all learners (caregivers to observers), where the learners do most of the talking.
The debriefing environment should be a safe environment where learners can engage in meaningful discussion. Debriefing in the context of simulation involves reflective observation and abstract conceptualization.
Reflective observation has its roots in Gestalt psychology and in the works of Lewin (1951); Beautiful (1987); Diefenbeck , Plowfield , and Herrman (2006); and Kolb (1984). Kolb (1984) and others ( Sewchuck , 2005; Svinicki & Dixon, 1987) suggest that the experiential learning cycle is a continuous process in which knowledge is created by transforming experience.
Individuals have a concrete experience, they reflect on that experience (reflective observation), they derive meaning (abstract conceptualization) from the experience, and they try out or apply (active experimentation) the meaning they have created, thus continuing the cycle with another concrete experience.
Debriefing encompasses the cognitive domain assessing knowledge; the kinetic domain assessing skill and action; and the affective domain, or how the learner felt or interacted with the patient or other staff. The role of faculty in facilitating simulation exercises is to support participants in the reflection and debriefing process.
Objectives of debriefing include the opportunity for the learners to describe what the experience was like for them; This includes a release of emotional tension about the experience, a guided review of the patient and objectives, the identification and sorting of thinking, and reinforcement of teaching and correction of misconceptions.
Debriefing is an opportunity to reference real-life experiences, normalize behaviors, and acknowledge emotions. Debriefing strategies are varied and several models are used in the simulation setting (Cheng et al., 2014; Simon, Rudolph, & Raemer, 2009; Waznonis , 2014).
The National League for Nursing in its Vision Statement, Debriefing Across the Curriculum, recommends that faculty use evidence-based resources to develop their skills in debriefing (National League for Nursing, 2015).
The Debriefing Assessment for Simulation in Healthcare (DASH) tool is designed to evaluate and develop the debriefing skills of the facilitator. This tool evaluates the facilitators’ ability to conduct debriefings following specific behaviors. It is an evidence-based tool designed according to how people learn and change in experiential learning and was reviewed by an expert panel at Harvard.
Facilitators face challenges in debriefing, including blame-setting for performance, statements such as “this wouldn’t happen in real clinical,” learners who are open with dislike about the learning environment, learners who are hostile and defensive or who are self critical and defeated based on performance.
Facilitators provide a safe, nonjudgmental environment and coach students to reflect on what they saw, heard, and experienced. All debriefings should be well planned and structured. The key for faculty during debriefing is not to provide more information or to lecture on the “correct” way or answer, but to guide students along the path of reflection.
Open ended questions, silence, and pauses help elicit feedback from learners and encourage active participation. Identification of a “take-away” message or transfer of learning to other situations should be included (Lusk & Fater, 2013).