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).