Generally, in simulation-based learning, we are dealing with educating the adult professional. Adult learning provides many challenges not seen in the typical student population. Adults arrive complete with a set of previous life experiences and frames (“knowledge assumptions, feelings”), ingrained personality traits, and relationship patterns, which drive their actions.
Adult learners become more self-directed as they mature. They like their learning to be problem centred and meaningful to their life situation and learn best when they can immediately apply what they have learned.
Adults learn best when they are actively engaged in the process, participate, play a role, and experience not only concrete events in a cognitive fashion, but also transactional events in an emotional fashion. The learner must make sense of the events experienced in terms of their own world.
The combination of actively experiencing something, particularly if it is accompanied by intense emotions, may result in long-lasting learning. This type of learning is best described as experiential learning: learning by doing, thinking about, and assimilation of lessons learned into everyday behaviours.
In his work in 1984, Kolb described the experiential learning cycle as containing four related parts: concrete experience, reflective observation, abstract conceptualisation, and active experimentation. Gibbs also describes four phases: planning for action, carrying out action, reflection on action, and relating what happens back to theory. Grant and Marsden similarly describe the experiential learning process as having an experience, thinking about the experience, identifying learning needs that would improve future practice in the area, planning what learning to undertake, and applying the new learning in practice.
Simulation training sessions, which are structured with specific learning objectives in mind, offer the opportunity to go through the stages of the experiential cycle in a structured manner and often combine the active experiential component of the simulation exercise itself with a subsequent analysis of, and reflection on the experience, aiming to facilitate incorporation of changes in practice.
Simulation offers the opportunity of practiced experience in a controlled fashion, which can be reflected on at leisure. Experiential learning is particularly suited to professional learning, where integration of theory and practice is pertinent and ongoing. In experiential learning, the experience is used as the major source of learning, but it is not the only one. Both thinking and doing are required and must be related in the minds of the learner.
The concept of reflection on an event or activity and subsequent analysis is the cornerstone of the experiential learning experience. Facilitators guide this reflective process. Indeed, this ability to reflect, appraise, and reappraise is considered a cornerstone of lifelong learning. In practice however, not everyone is naturally capable of analysing, making sense, and assimilating learning experiences on their own, particularly those included in highly dynamic team-based activities.
The attempt to bridge this natural gap between experiencing an event and making sense of it led to the evolution of the concept of the “post experience analysis” or debriefing. As such, debriefing represents facilitated or guided reflection in the cycle of experiential learning.
The concept of debriefing originated in the military in which the term was used to describe the account individuals gave on returning from a mission. This account was subsequently analysed and used to strategise for other missions or exercises. This military-style debriefing was both educational and operational in its objectives. The military style of debriefing uses a narrative approach and allows them to create a form of therapeutic or psychological association – a sort of “defusing,” and aided the processing of a traumatic event with the aim of reducing psychologic damage and returning combatants to the frontline as quickly as possible.
This narrative approach allows cognitive reconstruction of events which were performed in groups so that there was a shared meaning. The participants were brought together to describe what had occurred, to account for the actions that had taken place, and to develop new strategies with each other and the commanding officers.
Critical incident debriefing is another type of debriefing that can be used to mitigate stress among emergency first responders or through scenarios that are particularly stressful or emotive. This is a facilitator-led approach which enables participants to review facts, thoughts, impressions and reactions after critical incidents. The main aim of critical incident debriefing is to reduce stress and accelerate normal recovery after a traumatic event by stimulating group cohesion and empathy.
Setting the scene or prebrief
There is an ethical duty for the facilitators or debriefing team to create ‘a safe learning environment’. This is a confidential and supportive environment to attempt to protect the participants emotionally to maximise the learning experience. Participants should feel they can share their experiences in a frank open and honest manner. This safe learning environment must be created early on during the prebrief session. Other things to discuss in the prebrief are to run through the purpose of the session, the learning objectives, the purpose of debriefing and what it entails. The prebrief is also a good opportunity to set the ground rules for the session and for the facilitators to establish the experience of the group and to relate this to the learning objectives to allow them to maximise value of the session for the group. This facilitator responsibility (reflection on the group experience) is vital as the scenarios and debriefing techniques used need to take the individual learning styles of the group into consideration.
Learning Styles
Every learner will have a different patterns of learning style and will interpret scenarios differently. This is why it is very important for the facilitators to ensure they know the learner group so they can carry out the debrief in a particular way. This all comes back to experiential learning and Kolb’s learning cycle. There are four main learning styles: diverging, assimilating, converging and accommodating.
Diverging:
This learning style uses concrete experience and reflective observation to learn. This style facilitates generation of ideas, such as brainstorming. Individuals with this learning style prefer to work in groups, listening and receiving feedback.
Assimilating:
This learning style prefers abstract conceptualisation and reflective observation. They like reading, lectures, and analysis.
Converging:
This learning style uses abstract conceptualisation and active experimentation. They like to find practical uses for ideas and theories. In a formal learning setting, they prefer to experiment with new ideas, simulations, laboratory experiments, and practical applications.
Accommodating:
This learning style uses concrete experience and active experimentation. People with this style learn primarily from hands-on experience. In formal learning, they prefer to work in teams, to set goals, to do fieldwork, and to test different approaches to compiling a project.
When a group of learners are in a team, the individuals tend to orientate themselves and contribute to the team learning process by using their own learning styles to help the team reach its learning objectives.
Effective teams are made up of a spread of the different learning styles above. This team composition is an important factor for facilitators to consider when choosing a debrief style. It is also important for facilitators to know whether the participants know each other, their experience level and whether they are new to simulation or not.
Poor planning, a hasty prebrief or not considering learning styles and the group experience can result in a challenging and ineffective debrief.
There are a lot of different debriefing models but all of them contain similar structural elements. They all aim to enhance the educational experience of the learner and relate to the cycle of experiential learning mentioned above – the way humans have learned and developed for thousands of years.
Although reflection may occur naturally after an event, it is likely to be unsystematic or may not occur at all especially if the pressures of an event in the workplace prevents an individual focussing on what actually happened. By having a structured debrief allows the group to focus on the reflective process both for individual participants and for the group as a whole.
Without a facilitator or ‘debriefer’ the group of participants are likely to dwell on the descriptive phase, in particular the team leader or the team member in the hot seat who may have been task focussed or ‘blinkered’ from the other important things that were going on.
The role of the debriefer is to allow enough time for defusing to occur and discussion of the participants individual reactions and feelings without allowing a ‘personal narrative’ to run on for too long. This allows the whole group to benefit by bringing the discussion to a more objective and broad based capacity. This must be done in a sensitive way by not cutting an individual off or alienating them.
This text was taken from Fanning and Gaba’s review article in Simulation in Healthcare: Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: July 2007 - Volume 2 - Issue 2 - p115-125
Latent threats:
Latent safety threats are system-based threats to patient safety that can materialise at any time and are previously unrecognised by healthcare providers, unit directors or hospital administration. By highlighting latent threats to others can help make system wide changes and improve patient safety.
Using In situ Simulation to identify Latent threats:
There is evidence that regular simulation sessions for acute cases including human factors training improves safety critical behaviours and more crucially, patient outcomes. In situ simulation has been described as ‘crash testing the dummy’.
More formally, In situ simulation is a team based training technique conducted in actual patient care units using equipment and resources from that unit and involving actual members of the healthcare team. While simulation has often been used as a strategy to train individuals in both technical and non technical skills, in situ simulation can be used to evaluate system competence and identify latent safety threats that predispose to medical error.
Below are some latent safety threats either identified by in situ simulation or from clinical practice:
