Medical Simulation Design and Debriefing strategies

1. Medical Simulation:
Scenario Design and Debriefing
Rob Parker, DO
July 2017

2. Introduction
 What is Simulation?
 Why Simulation?
 Scenario Design
 Debriefing

3. Theories of
Learning

4. Adult Learners
• Adults need to know why they need to learn something
• Adults have some degree of self-motivation
• Adults approach learning as problem solving
• Adults learn best when the topic has immediate value
• Adults need to learn experientially
• Adults bring their prior experiences/beliefs with them

5. National Training Laboratories,
Bethel, Maine; 1969
Lecture
5%
Reading
10%
Audiovisual
Information
20%
Demonstration
30%
Group Discussion
50%
Learning by Doing
75%
Teaching Others
90%
Passive training
Active training
KnowledgeRetention
Pyramid of Learning

6. What is Simulation?
 “Simulations are created experiences that mimic processes or
conditions that cannot or should not be experienced firsthand
by a student because of the student’s inexperience or the risk
to the patient (Morton, 1997).”
 “Simulation is a technique…to replace or amplify real
experiences with guided experiences that evoke or replicate
substantial aspects of the real world in a fully interactive
manner (Gaba, 2004).”
 “Simulation is a generic term that refers to the artificial
representation of a real-world process to achieve educational
goals via experiential learning (Flanagan, Nestel, & Joseph,
2004).”

7. What is Simulation?
 “Simulations are created experiences that mimic processes or
conditions that cannot or should not be experienced firsthand
by a student because of the student’s inexperience or the risk
to the patient (Morton, 1997).”
 “Simulation is a technique…to replace or amplify real
experiences with guided experiences that evoke or replicate
substantial aspects of the real world in a fully interactive
manner (Gaba, 2004).”
 “Simulation is a generic term that refers to the artificial
representation of a real-world process to achieve educational
goals via experiential learning (Flanagan, Nestel, & Joseph,
2004).”

8. Simulation is:
Created, guided experiences that mimic real-
world processes or conditions to achieve
educational goals via interactive, experiential
learning

9. Tenants of Simulation
1. Feedback is provided during the
learning experience
2. Learners engage in repetitive
practice
3. The simulator is integrated into
the medical curriculum
4. Learners practice with increasing
levels of difficulty
5. The simulator is adaptable to
multiple learning strategies
6. The simulator captures clinical
variation
7. The simulator is embedded in a
controlled environment
8. The simulator permits
individualized learning
9. Learning outcomes are clearly
defined and measured
10. The simulator is a valid (high-
fidelity) approximation of clinical
practice

10. Medical Education in the Pre-Simulator EraExpertise
Time
Advanced
Clinical
Expertise
1st Year Med Student
4th Year Med Student
Internship
Senior Resident
Fellowship
Junior Attending
Basic
Science
Clinical Exposure
Early Clinical Decision Making
Advanced Clinical Decisions
Clinical Responsibility
Darby. 2014

11. Expertise
Time
Advanced
Clinical
Expertise
1st Year Med Student
Internship
Senior Resident
Fellowship
Simulation
as Adjunct
Medical Education in the Post-Simulator Era
Darby. 2014

12. How Sim Works

13. Created, guided experiences that mimic real-
world processes or conditions to achieve
educational goals via interactive, experiential
learning

14. Stress and Performance in Simulation

15. Stress and Performance in Simulation

16. Goals of a Successful
Simulation
• Increase knowledge and
retention
• Improve team communication
and performance
• Practice! Practice! Practice!

17. Creating a Scenario

19. Step 1 - Perform a General Needs
Assessment
• Problem (Gap) =
• Ideal Situation –
Current Situation
• The Idea Comes
from the Gap

20. Step 2 - Create Objectives
Who will do .. how much ..
of what .. by when

21. Step 3 - Tell the story
 Write the story in 10
words or less
“A infant with
bronchiolitis developed
respiratory failure
requiring intubation”

22. Step 4 – Story to Scenario
 1. Story pitch
 2. Story structure
 3. Story Narration
 4. Screenplay
 5. Storyboard

23. The 3 Act Structure
1. The team receives an infant in
respiratory distress
2.The team recognizes respiratory
failure and responds appropriately
3.The team intubates the baby and saves
the day!

24. The Story
 2 month old male presents with bronchiolitis. He was
admitted overnight to the inpatient unit and was provided
usual care with NC O2. His clinical status deteriorates
such that he requires ventilatory support via Vapotherm
(HFNC). Patient requires escalating respiratory needs
prompting a Rapid Response to be called. Patient requires
intubation at which point his condition stabilizes and he
can be transferred to the intensive care unit.

25. Step 5 – Create the StoryBoard

26. Running the Case
 Determine what action is going to trigger the next step
 Ex. Failure to recognize worsening sats  apnea
 Ex. Increase respiratory support and 5 minutes passed
 Ex. Team effectively intubates patient and saves the day

27. Step 6 – Create the Assessment
 How do you know that the
learners are learning?
 Self Assessment
 Peer Assessment
 Expert Assessment
 Make Sure to Identify the
Key Components that all
learners must take away

28. Step 7 – List the Resources
 1. Simulators
 2. Medical Equipment
 3. Adjuncts & Props
 4. Moulage
 5. PC & Software
 6. A-V Equipment
 7. Documents

29. Step 8 – Prepare the Stage
• Make sure you
have the
equipment, space,
resources, props
and a flow to the
scenario

30. Step 9 – Ready For Action!

31. Step 10 – Action!

32. Debriefing

33. Bring Meaning to Simulation
Debriefing is the most important feature of
simulation-based medical education.
– Safely and critically provide constructive feedback
– Recognize any potential bias
– Understand where the learners are coming from
and restructure their framework

34. Debriefing Basics
 The terms debriefing and feedback are sometimes used
interchangeably
 Debriefing is facilitated discussion of an event - with
goal of improving future performance

35. Basic Structure
 Prebrief
 Reactions phase
 Gathering Understanding Phase
 Summarizing/Reviewing Phase
 Planning for the next time

36. Prebrief
 Set the stage –
– “There will be a 15 minute scenario after which we will take time to
decompress then talk about what we hoped you got out of the
scenario”
 Create a culture of safety –
– “This is a chance to make mistakes, we all make them, to learn from
them and to become better in the future.”
 Introduce the participants to the mannequin –
– Have them look, listen and feel
 Ask them to act as if they would in real life –
– “If you would put in an IO then put in an IO. If you would suction the
patient, then do that.”
 Ask them to verbalize their thoughts –
– “Talk out loud so everyone can here and understand where you are
coming from.”

37. Objectives Guide
The Debriefing

38. Mind the Gap

39. Methods of Debriefing
Framework Phases Meaning
Good Judgement • Reactions
• Analysis
• Summary
• Explore feelings and “blow off steam”
• Identify performance gaps, give feedback on gaps, investigate where
person is coming from, commence discussion and didactics
• Distill lessons and codify insights gained during analysis phase
GAS • Gather
• Analyze
• Summarize
• Team leader provides narrative of events with supplementation from team
• Pointed questions are used to stimulate reflection and shed light on
thinking process
• Verify all important points and review lessons learned
AAR • Define
• Explain
• Benchmark
• Review
• Identify
• Examine
• Formalize teaching
• Define the rules of debriefing (safe learning, trying to get better, etc.)
• Explain the learning objectives
• Explain performance standards
• Review what the expected actions were
• Identify what actually happened during simulation
• Examine why things happened and provide feedback on performance
gaps
• Formalize learning with a focus on what went well, what did not, and what
people would do different next time
TeamGAINS • Reactions
• Clinical Debriefing
• Transfer
• Behavioral Skills
Discussion
• Summarize
• Repeated practice
• “How did that feel?”
• Debriefing of the clinical components of the scenario
• Transfer from simulation to reality (“how would this look in real life?”)
• Discussion of behavioral skills and relation to clinical outcomes
• Summarize the learning experience
• Supervised practice of the clinical skills

40. FFAST

41. PEARLS

44. Advocacy and Inquiry
Advantages
 Promotes reflective
learning
 Allows for understanding
of frames/rationale
 Promotes group
discussion
 Explores team dynamics
Disadvantages
 Can be time consuming
 Very difficult to master
 Risks the conversation
going off topic

45. Directive Feedback
Advantages
 Rapidly closes
performance gap
 When rationale is not
present, discussion is not
required
 Time efficient
 May be best to use with
procedural tasks or
novice learners
Disadvantages
 Assumes that rationale is
incorrect
 Does not explore
frames/rationale
 May be taken in the
wrong way if not
delivered well
 Pedagogical
 Limits group discussion

46. Plus/Delta
 Combines things that have gone well (pluses)
 With things that could change (delta)
 A variation of the “feedback sandwich”

47. PEARLS Debriefing Script
Setting the scene
• ‘‘I’ll spend about XX minutes debriefing the case with you.
• First, I’ll be interested to hear how you are feeling now that that case is over
• Second, I’d like someone to describe what the case was about to make sure we are all on the same page.
• Then, we’ll explore the aspects of the case that worked well for you and those you would manage differently and why. I’ll be interested to
hear what was going through your mind at various points in time.
• We’ll end by summarizing some take-home points and how to apply them in your clinical practice.’’
Reaction
• “‘How are you feeling?” “How are the rest of you feeling?”
Description
• “Can someone summarize the case from a medical point of view so that we are all on the same page?’’
• ‘‘From your perspective, what were the main issues you had to deal with?’’
• “What happened next?” “How did the team respond?”
Analysis
• “Now that we are clear about what happened, let’s talk more about that case. I think there were aspects you managed effectively and
others that seemed more challenging. I would like to explore each of these with you.’’
Learner Self-Assessment
• “What aspects of the case do you think
went well?”
• “What aspects of the case would you
want to change?”
Directive Feedback and Teaching
• Provide relevant information or tips to
perform the actions correctly
• “I noticed you [ ]. Next time, you may
want to [ ] because [rationale].”
Facilitation
• Specifically state what you would like
the to talk about (“I would like to take a
few minutes to talk about XXX”
• Elicit the rationale for these actions
Are there any outstanding points that people would like to go over before we close?
Applications/Summarizing
• Learner Driven: “I’d like to close by having each one of you state a take away point.”
• Instructor Driven: “In summary, the key learning points from this case were …”

48. Questions?