A N D R E W S M I T H M D , B E T H V U K I N M D , J U L I A W H I T A K E R M D ,

M A D D I E L A S S C H E R N

NEXT STEPS IN INTERPROFESSIONAL EDUCATION

HIGH FIDELITY SIMULATION AND DEBRIEFING

INTERPROFESSIONAL EDUCATION (IPE)

“Interprofessional education occurs when students from two or more

professions learn about, from, and with each other to enable effective

collaboration and improve health outcomes. Once students understand

how to work interprofessionally, they are ready to enter the workplace as

a member of the collaborative practice team. This is a key step in

moving health systems from fragmentation to a position of strength.”

Source: World Health Organization (WHO). (2010). Framework for action on interprofessional

education & collaborative practice. Geneva: World Health Organization.

See http://whqlibdoc.who.int/hq/2010/WHO_HRH_HPN_10.3_eng.pdf.

INTERPROFESSIONAL EDUCATION (IPE)

IPE Competency Domains

1 • Values/Ethics

2 • Roles/Responsibilities

3 • IP Communication

4 • Teams and Teamwork

SIMULATION FOR IPE (EXAMPLE)

Disaster Essentials for Healthcare Professionals • Integration of IPE Core Competencies

• Experience both provider and patient role

• Teamwork skills in high stress environment

WHY USE SIMULATION?

ADULT LEARNERS-EXPERIENTIAL LEARNING

• Adults learn best when they are actively engaged

• Experience the events…

• in a concrete fashion

• in a cognitive fashion

• in an emotional fashion

KOLB CYCLE OF EXPERIENTIAL LEARNING

Simulation/Clinical experience

Debriefing

WHY SIMULATION?

DESIGNING A SIMULATION SCENARIO

GROUP ACT IVI TY

THE BASICS

• Who are your learners?

• What are your educational

goals, objectives and

debriefing points ?

• How will you get them actively enaged? What type

of simulation will you use?

• What resources do you have

at your disposal?

• The nitty gritty details

• L-earners

• E-ducational objectives

• A-ctive involvement

• R-resources

• N-itty gritty details

WHO ARE YOUR LEARNERS?

• What school?

• What year in training?

• What do they already

know?

• What clinical experience

do they have?

• L-earners

• E-ducational objectives

• A-ctive involvement

• R-resources

• N-itty gritty details

WHAT ARE YOUR EDUCATIONAL GOALS AND OBJECTIVES?

• Physiology

• Procedural skills

• Communication

• Team training

• Resuscitation skills

• L-earners

• E-ducational objectives

• A-ctive involvement

• R-resources

• N-itty gritty details

MAJOR DEBRIEFING POINTS

• What are my main learning objectives?

• The bulk of your planning time and sim time should be spent here…

HOW WILL YOU ACTIVELY ENGAGE THEM? WHAT TYPE OF SIMULATION WILL YOU USE?

• Standardized patients

• Task trainers

• Low fidelity simulation

• High fidelity simulation

• L-earners

• E-ducational objectives

• A-ctive involvement

• R-resources

• N-itty gritty details

STANDARDIZED PATIENTS

Communication training

• Basics of talking with patients

• Taking a history

• Physical exam skills

• Breaking bad news

• Error disclosure

Points to discuss

• Body language

• Tone of voice

• Words used

TASK TRAINERS

Procedural skills • Prep

• Drape

• Positioning

Anatomy/landmarks/sensitive exams

Examples • LP

• IO

• Intubation

• Bag mask ventilation

• Central lines

• Breast/pelvis models

LOW FIDELITY SIMULATION

• Fidelity refers to the degree of “realism”

• Mannequins can be “low” fidelity but used in a “high” fidelity simulation

• “High” fidelity mannequins are not always needed for a “high” fidelity simulation

• “Low” fidelity mannequins or equipment that give minimal feedback

• Example: PALS training

HIGH FIDELITY SIMULATION

• MORE realistic simulation with high degree of feedback (debriefing)

• “Low” or “high” fidelity mannequins can be used in a “high” fidelity

simulation

• Bigger cost/time and labor utilization so often best for “larger scale” teaching

topics

Examples

• Team resuscitation

• Team communication

• Advanced resuscitation

• Multiple diverse objectives

• i.e. communication WHILE performing a skills

WHICH IS RIGHT FOR YOU?

• Start with your goals and objectives

• Can you accomplish your goals with other modalities?

• Use the lowest fidelity mannequin with lowest resource utilization that is

needed for the objective

• If high fidelity simulation is needed, consider low tech options to deliver

the highest level of realism

THE RESOURCES

• What resources do you

have at your disposal?

• SPs

• Confederates

• Simulation equipment

• How much time do you

have?

• How many learners at a time

• How many faculty

• L-earners

• E-ducational objectives

• A-ctive involvement

• R-resources

• N-itty gritty details

THE NITTY GRITTY DETAILS

• The history • How will you give it to the students?

• Prescripted

• “Door note”

• Ask the bedside nurse/parent

• Phone call

• The physical • What can your tools display?

• Mannequin vs. SP

• “Door note”

• Verbal description/nursing report

• Room set-up & “noise”

• How will it play out? • Static

• Changing

• What will the patient do?

• Can the students intervene?

• Revisit your goals and objectives

• L-earners

• E-ducational objectives

• A-ctive involvement

• R-resources

• N-itty gritty details

BRIDGING THE GAP

• The best simulation takes students from where they are in learning to

where they need to go…

• If the gap is too small, they are bored

• If the gap is too big, they are lost

BUT REALLY… IT IS ALL ABOUT FACILITATION

• Simulation is an ideal way to engage students and enhance their

experiential learning

• But really everything is learning– with the right facilitation

KOLB CYCLE OF EXPERIENTIAL LEARNING

Simulation/Clinical experience

Debriefing

DEBRIEFING

DEBRIEFING

ADULT LEARNERS

• Adults have a set of previous life experiences, personality traits and

relationship patterns that drive their actions.

• Self directed.

• They like their learning to be problem based and meaningful to their

life situation.

• They learn best when they can immediately apply what they are

learning.

ADULT LEARNERS EXPERIENTIAL LEARNING

• Adults learn best when they are actively engaged

• Experience the events in a concrete fashion

• AND in a cognitive fashion

• And in an emotional fashion

KOLB CYCLE OF EXPERIENTIAL LEARNING

Simulation/Clinical experience

Debriefing

DEBRIEFING

What is debriefing

• This term originated in the military to describe the account individuals

gave on returning from a mission

• Defusing-aided the processing of a traumatic event to accelerate

recovery

• Depended on a narrative account of what happened to develop

new strategies

• Also used in experimental psychology

FACILITATOR-LED DEBRIEFING

• A discussion of events, reflection and assimilation of activities into their

cognition to produce long lasting learning.

BREAK THAT DOWN

• Facilitator – led

• Participant discussion of events

• Reflection

• Assimilation of activities into their cognition

• To produce long lasting learning.

FUNDAMENTALS OF DEBRIEFING

• There are emotions involved

• Learners can feel exposed

• Psychological safety and a supportive environment is needed

• how do we do that?

OBJECTIVES OF THE DEBRIEFING

• These may be well defined or may emerge during the simulation

THE ROLE OF THE FACILITATOR

• There is tension between making the participants active and

responsible for their learning and ensuring they are addressing

important issues

• The skill of the debriefer has the highest correlation to the perceived

learning experience

HOW MUCH FACILITATING?

• That depends

• The objectives

• The complexity of the scenario

• The experience of the participants with the scenario and with the

context (sim/clinical)

• Time

• People involved

DEBRIEFING STYLES

• Level of facilitation:

• Teacher style

• The guide

• Fly on the wall

• Level of participant activity:

• Low

• Intermediate

• High

What is the

“best”?

LOW FACILITATOR INVOLVEMENT

• Level of participant activity:

• Low

• Intermediate

• High: the facilitator asks a few questions to guide the discussion

PROFICIENT TO EXPERT LEARNER

• Level of participant activity:

• High: the facilitator asks a few questions and guides the discussion

• How did that feel?

• What could we have done differently?

• What would we do again?

• How will this change your practice?

• Reflection on action

• The experience provides a context for discussion and improving

outcomes

HIGH FACILITATOR INVOLVEMENT

• Level of participant activity:

• Low: the facilitator almost becomes the teacher, socratic method

• Intermediate

• High

THE NOVICE LEARNER

• Level of participant activity:

• Low: the facilitator almost become the teacher, socratic method

• How did that feel?

• Tell me about that?

• Let’s talk about ______

• What do you know about ______

• Didactic session after an experience

• The experience provides a context and exposes knowledge gaps

INTERMEDIATE FACILITATOR INVOLVEMENT

• Level of participant activity:

• Low

• Intermediate: the facilitator is a co-learner-exploring ideas

• High

ADVANCED BEGINNER/PROFICIENT

• Advocacy Inquiry Debriefing

• …a standpoint of curiosity,

mutuality, and respect.

• DO share observations based on

expertise

• DON’T assume a stance of

certainty on WHY it happened…

• ASSUME the participant is

intelligent, educated, and wants

to improve

• ASSUME there is something for

you to learn

ADVANCED BEGINNER/PROFICIENT

Advocacy Inquiry Debriefing

• Advocacy – State what you observed or your

concern clearly

• Don’t play “guess what is in the facilitator’s head”

• Do be honest and open regarding your observations

• Do be cognizant of your tone… does your voice

convey neutrality or hostility?

• Inquiry – Seek to understand why with curiosity and

respect

• Don’t ask leading questions

• Do ask questions regarding action or inaction

• Do use a tone of curiosity

• The statement and question should convey non-

judgmental inquiry while maintaining trust

DEBRIEFING ACTIVITY

CAN WE HAVE 7 VOLUNTEERS?

USE OBJECTIVE TO GUIDE IPE DEBRIEFING

IPEC Objectives for IPE

1. Values & Ethics • Mutual Respect

2. Roles & Responsibilities • Know your role and

other’s roles

3. Interprofessional

Communication • Share expertise

4. Teams & Teamwork • Relinquish autonomy,

focus on the patient

DEBRIEF THE DEBRIEFING

TECHNIQUES AND TIPS

• Set the stage

• Set your expectations

• Tone of voice

• Body language

• Facial expression

• Encourage participants to answer own questions

• Ensure participants do most of the talking

• Adapt level of facilitation to use capabilities of participants (customize)

• Development of a checklist or “debriefing guide” to use during the

debriefing

PITFALLS TO AVOID

• Unwittingly controlling discussion

• Lecturing/ instructor-centered instead of instructor-LED

• Giving own analysis/ evaluation

• Impression that only your perspectives are important

• Interrupting discussion

• Interrogation

• Rigid agenda

• Concentrating on errors

• Not having sufficient time

DISCUSSION – ANDY SMITH, MD