Today the discussion in Sim-one training around simulation continued. We began by reflecting on our wish-list and availability of current resources. While Cambrian has access to wonderful resources we still have quite a wish-list of technology and human resource support.

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Without knowing it we often combine different modalities of simulation to address student needs. Combining online simulations with in-person approaches seems to happen naturally.

Success and Challenges

Debriefing is critical to the success of simulations. There are a lot of excellent strategies being used to promote the success of debriefing. Educator work to provide feedback as soon as possible, build student confidence, set clear expectations, reward students with grades for hearing feedback, creating a respectful environment, using standardized patients, careful planning, and the use of online modules to provide immediate feedback for students.

There are also a lot of challenges to doing it well. Common themes included:

  • providing timely feedback to individuals
  • the time needed to properly debrief
  • inter-rater reliability challenges
  • limited materials
  • fatigue

Can-Sim

Collaboration within and across institutions helps to address some of the challenges inherent in simulation development. The Can-Sim alliance got a shout-out from the facilitators of the session. As a recent member I see value in engaging with this community. The largest barrier is knowing what and how we can share resources with institutional permission. A great suggestion to build a business case for contributing gave me some hope for becoming a more active contributor to the community.

Facilitation

It can be challenging to stay in the role of a facilitator as opposed to a teacher in debriefing situations. The role we take may depend on the needs of learners, purpose of the simulation and contextual factors. For me I have a difficult time allowing students to engage in self discovery at times because it requires them to leave the class and it is hard to follow up sometimes. I like the idea of having a scribe and doing concept mapping to identify discussion points. Discussion of scenarios can often deviate from the learning outcomes of the course. As awesome as that is we as facilitators need to focus and guide the conversation to ensure the outcomes are met.

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We also need to set and enforce ground rules. This role is easier discussed than enforced. Some good strategies were discussed for dealing with disruptive students and setting expectations. Actionable items include the development of contracts and addressing problematic student behaviour by checking-in with the student and addressing concerns from a safety perspective. I think signing contracts is a good idea.

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Developing and maintaining trust with everyone involved is critical. Once trust is broken it is difficult to maintain. Consistency between groups and proper follow-through is important. When rules are set it is important to discuss how to consistently respond to student situations with the support of management. I think that establishing consistency is an ongoing challenge that will take time to address.

Woman with hands on temples looking overloaded
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Cognitive Overload

If scenarios are too complex we may shut-down learning or foster biases. We need to think carefully about the level of realism or challenges incorporated to ensure it helps students meet the learning outcomes of the simulation. We need to be mindful of the potential for cognitive overload for both educators and students. One person and only manage or learn so much.

Structure

A theoretical framework can be useful to structure the debrief. It facilitates structure and consistency for students. Over the past year I have learned that students need highly structured environments and step-by step instructions to navigate through meeting our expectations. They seem to get easily anxious without checklists and consistent instructions in multiple formats.

Reflection

Students and educators alike need the time to reflect on their experiences to promote learning and self-improvement. Blogging is a form of reflection for me. This is how I process information. Another helpful strategy is discussion with others. I wish I had more time for that. We need to make more time to reflect as educators as a group.

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We also need to help students unpack the student experience and develop capacity to be effective and safe practitioners. Establishing meaning with essential for adult learners to fully engage in an activity. Learning is influenced by the environment and interactions among participants. As educators we need to create the conditions for success for our learners. The debriefing of a scenario is critical in accomplishing deep reflective and meaningful learning for students.

How can we make competition healthy?

Competition can make people want to do better. However, it can also be negative and disruptive to the learning. In simulations, focusing on the patient may help to mitigate unhealthy competition. Sometimes the root of the problem may be fear. Addressing the root cause of the issue may solve the problem. It may also be driven by the evaluative structures in the course. Is there something about the way the course is set up that promotes collaboration or competition?

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Process Familiarity

Students need to become familiar with the process used for simulation. Once the rules and roles are practiced students get better at it. Scaffolding learning is important for novice learners.

Focus on Realistic Outcomes

Throughout the day the answer to many questions was it depends on the learning outcomes. Planning what you want students to achieve before formulating any other aspect of the scenario is important. We talk a lot about learning outcomes and backwards course design in the Hub. SMART goals help to keep the design of the simulation focused. The facilitators suggest focusing on only two to three outcomes per scenario. The outcomes should, in my opinion, come before the development of the scenario. That is how they were developed in my course this term.

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However, when you have a simulation that is already created it is possible to pull out the outcomes from the simulation that make sense for the course. It is also possible to use the same simulation across courses or terms to accomplish additional outcomes.

Rubrics

Rubrics can provide a structure for objective and consistent debriefing guidance. This year I have grown a lot in the language, process and approach I use to develop rubrics. Co-construction of the rubric with students is something I have found to work well to clarify assignment expectations with students. Hopefully I can blog more about how well it worked this term with additional step-by-step guidance for year one students. Some other quick tips include:

  • It is important that the criteria be measurable and objective.
  • The ability and space to add comments on the rubric is useful.
  • I prefer having the top level on the left so students can focus on the end goal.

The value of the simulation is in the debriefing.

More time and attention is needed to focus on debriefing effectively when facilitating simulations. Different models of time can be used to debrief. One recommendation was to use dedicate twice the time to debriefing than the scenario. For example, a 15 min simulation may be followed by a 30 min debriefing session.

When making observations we can see what students did but not why they did it. The briefing session is where rich discussion can happen and reasons for their actions can be explored.

Briefing (Before the Scenario)

The purpose of the pre-briefing for scenarios is to create a psychologically safe environment for simulation. Normalizing mistakes, establishing a non-judgmental atmosphere and orientation to the scenario and facilitator are essential components.

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The Facilitator is Key

The facilitator needs to normalize mistakes, establish trust, consistent and reliable. Orientation to the environment is critical to the student’s ability to succeed. The facilitator needs to let students know the expectations of the simulation and limitations of the equipment. A clear understanding of the objectives of the simulation should be part of the orientation to the simulation. Each player in the scenario needs role clarity – to know their role, conditions under which they should respond and what their objectives are. Standardized patients, facilitators and technicians also need to be briefed.

I find that a lot of the characteristics of a good facilitator mirror the characteristics of a good clinical educator. Being approachable and empathetic to students is important to ensure students feel safe engaging in the simulation. Providing good, constructive, future-focused suggestions for improvement is critical for establishing an effective teaching-learning relationship.

Essential Information

  • Is it summative or formative?
  • Ground rules
  • Explicit learning objectives
  • Any actors/who is involved
  • Expectations
  • The beginning and ending points
  • What the debrief will look like
  • Logistics

Students need extremely clearly articulated instructions to feel comfortable engaging in the activity. I have found that true in all learning situations.

Engaging Observers

Engaging observers can be a challenge. Observer tools can help to engage learners. Another strategy is to build-in the requirement of students to switch places during the simulation. Observers could be given the role of initiating the discussion during the debriefing. Keep in mind that when students are given specific tools they may miss other things that are happening in the scenario because they are focused on the task at hand. Watch the video below and see if you can count the number of times the people wearing white pass the ball.

Ongoing Discussion

Please reach out if you want to talk more about simulation. Simulation is an innovative strategy to improve education that takes some careful planning in order to maximize it’s efficiency. I would love to see how you are using it or thinking of using it in your context. By sharing our approaches we can achieve more meaningful learning experiences for students.

Laura Killam

Thank you

I would like to thank Karl Weiss and his co-facilitator for sharing their experiences with us. It was a pleasure being part of the SIM-one Essentials and Briefing, Debriefing course held on February 25-27, 2019 at Cambrian College (Click here). I look forward to exploring simulation in more depth in the future.


NurseKillam

Laura Killam is an experienced nursing educator from Northern Ontario with a keen interest in improving student learning through innovation. For more information please visit http://nursekillam.com/.

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