Effective learning in simulation: how can we help?

Dr Lucas Opitz

CHU de Nice, France

What are we talking about?

• Medical training through simulation scenari

About the learning process

Hearing

Understanding

Saying

Doing

Teaching

Learning

Cognitive outcomes-Verbal knowledge- Knowledge organisation- Cognitive strategies

Skill-based outcomes- Compilation

-Proceduralisation- Composition

- Automaticity

Affective outcomes- Attitudinal- Motivational

- disposition- self-efficacy- goal-settingCognitive achievement

Application of cognitive, skill-based, and affective theories of learning outcomes to new methods of training evaluation.Kraiger, Kurt ed altriJournal of Applied Psychology78.2 (Apr 1993): 311-328.

Ouups, something did not go as smoothly as expected

Possible reasons of “failing”:– Attendants (knowledge, attitude, compliance)– Technical– Scenario– Briefing/Debriefing– Psycho-cognitive / communication / emotive

Attendants/trainees

• Compliance• Knowledge:

– Know less – Know better– Know differently

• Attitude – cf emotions

Briefing

• No debriefing without briefing• Axiom:

« We believe everyone participating in activities at the Center for Medical Simulation is intelligent, well-trained, cares about doing their best, and wants to improve »

• Be assured about compliance of trainee: agreements prior to scenario

• Thus: re-assure about psychologically safe environment• Rare: cases where the trainee is willfully negligent or

malevolent, this model does not work

Briefing

• Use advocacy-inquiry• Positive attributes of the approach: right from the start• Be clear about key learning objectives• Contextualisation• Understand trainees’ frames, assumptions• Cultures in which deferring to authority and elders: put a

frame

Technical

• Mannikin• Acoustic, video• Software

• Coordination• Curriculum writing

Scenari and realism

• As close as possible to (clinical/social) reality• Scenario writing (inside curriculum)• Time frame• Iterative testing, assessments• Plasticity, modulation according to dynamics

Scenari and realism

• Examples

How do we prepare a case?

Define objectives Construct scenario

Steer

Implement

Assess, review

Feedbacks(trainers, trainees)

Test

Re-Re-

Communication

• Emotions

“Exposure to a simulated crisis without constructive debriefing by instructors offers little benefit to trainees. The addition of video review did not offer any advantage over oral feedback alone. Valuable simulation training can therefore be achieved even when video technology is not available.”

Savoldelli GL, Naik VN, Park J, Joo HS, Chow R, Hamstra SJ St. Michael's Anesthesia Research into Teaching Simulation Group, Department of Anesthesia, St. Michael's Hospital, University of Toronto, Ontario, Canada.Anesthesiology [2006, 105(2):279-285]

Debriefing - why?

D’après Savoldelli G. Anesthesiology 2006

- Formative assessment, evaluation- Interactive phenomenons- Non-passionate analyses: knowledge, understanding,

capacities, behaviour, decisions- Interactions trainees/trainers- Analyse feelings, thoughts and emotions- Define what could be done for improvement- Critics should be honest, in a curious and respectful attitude

Rudolph W Acad Emerg Med 2008

Issenberg SB Med Teacher 2005

Mc Caghie WC. Med Educ 2009

Pelaccia Th. Pédagogie Médicale 2008

Ten Eyck RP Ann Emerg Med 2009

Debriefing: how?

Debriefing - about authority

- Summative evaluation versus formative evaluation- You cannot avoid judgements: give feed backs or

not?- Too liberal, no constructive analyses : what was the goal?- Cultures in which deferring to authority and elders is of paramount

importance: inhibits their disclosing views that may seem to contradict those of the instructor(M. St Pierre,G. Breuer: Simulation in der Medizin: Grundlegende Konzepte - Klinische Anwendung, Springer-Verlag 2013)

Debriefing

• Good Judgment:– Combining Rigorous Feedback with Genuine

InquiryJenny W. Rudolph Anesthesiology Clin 25 (2007) 361–376

• Medical students who received simulation training along with constructive feedback had an increased self-confidence

Dayal et alDayal AK, Fisher N, Magrane D, Goffman D, Bernstein PS, Katz NT. Simulation training improves medical students’ learning experiences when performing real vaginal deliveries. Simul Healthc. 2009;4:155-159

Debriefing with Good Judgment:– Neutral position when you receive– One’s views often leak by subtle cues, such as facial

expression, tenor, cadence, and body language- Instructors often avoid giving voice to critical thoughts

and feelings because they do not want to seem, worry that criticism might lead to hurt feelings or

defensiveness on the part of the trainee - Voicing critical judgment poses a dilemma for many

instructors ‘‘How can I deliver a critical message and share my expertise while avoiding negative

emotions, preserving social face and maintaining my relationship with the trainee?’’

- “Plasticity”

Reflective practice

BUT: - To avoid the judgmental approach is to choose silence and express no critical thoughts or feelings (?)- To obscure the expert critique, important insights or feelings related to the trainee’s performance remain murky or unexpressed- Thus trainees could be deprived of information that could improve work

Judgmental debriefingleading to:- humiliation, - dampened motivation, - reluctance to raise questions - exit of talented trainees from the specialty or clinical practice

Debriefing with good judgmentUnderstanding the frames (own and trainee’s)

means giving the ability to help

GAPS: 4-step-model

Debriefing as Formative Assessment: Closing Performance Gaps in Medical Education.Jenny W. Rudolph PhD, Robert Simon EdD, Daniel B. Raemer PhD andWalter J. Eppich MD, MEdArticle first published online: 20 OCT 2008DOI:†10.1111/j.1553-2712.2008.00248.

Formative assessments based on: 3,000 debriefings1) note salient performance gaps related to predetermined objectives2) provide feedbacks describing the gap3) investigate the basis for the gap by exploring the frames and emotions contributing to the current performance level4) help close the performance gap through discussion or targeted instruction about principles and skills relevant to performance

- Mental representation of external reality- Important role on decision-making- Debriefing allows to identify the frame Frame within clinical reality (scenario):

Identify gap between perception, reality and action

- Frame outside clinical reality (i.e.: social)

Frame

Debriefing with Good Judgment: Combining Rigorous Feedback with†Genuine InquiryJenny W. Rudolph, PhD, Robert Simon, EdD, Peter Rivard, PhD, Ronald L. Dufresne, PhD, Daniel B. Raemer, PhDDOI: http://dx.doi.org/10.1016/j.anclin.2007.03.007

Debriefing = Cognitive science, social, psychology, and anthropology

• Learn what frames drive trainee behaviours so that both

their failures and successes can be understood as an ingenious, inevitable,and logical solution to the problem

• Learn to scrutinize the taken-for-granted assumptions• Contextualisation - decontextualisation -

recontextualisation• People do not passively perceive an objective reality, but

engage in sensemaking by which they actively filter, create, and apply respective to their environment

Results

Debriefing

Mental frame

Actions

Organisation du debriefing

v Modèle de Rudolph« détourné » ;

v Check-list.

DU de Pédagogie et d’Enseignementpar Simulation

Debriefing• Checklist:

Technical:

Debriefing

• Checklist– Teamwork

• Effective teamwork crucial for optimal care in ICU. Team leadership seems vital for guiding the way in which ICU team

members interact and coordinate with others (Crit Care Med 2009; 37: 1787-93

• “A single exposure to anesthesia crises using a high-fidelity patient simulator can improve the nontechnical skills of anesthesia residents. However, an additional simulation session may confer little or no additional benefit.”(Yee B, Naik VN, Joo HS,

Savoldelli GL, Chung DY, Houston PL, Karatzoglou BJ, Hamstra SJPatient Simulation Centre, St. Michael's Anesthesia Research into Teaching (SMART) Simulation Group, St. Michael's Hospital, University of Toronto, Ontario, Canada.Anesthesiology [2005, 103(2):241-248]

Debriefing

• Develops and integrates insights from direct experience into later action.

• Provides a way for clinicians to explain, analyze, and synthesize information and emotional states to improve performance

• Feel challenged and psychologically safe enough

Success - Failing

Relaxed atmosphere Open questions Self-debriefing facilitated Open discussions on all technical aspects of

scenario Meccanisms of errors analysed (not just

pointed out) « Everybody makes mistakes » Concentrate on a limited number of objectives Identify the positive aspects of the session

Closed questions Critics Focalisation on errors Blaming, ridiculising Focalising too much on medical aspects (neglecting emotional parts) Too many objectives/teaching goals Long-lasting debriefings Long speaches during debriefing

Why write curricula?

• Basic documents • Showcase, credibility, reproducibility, example • Common platform inside the team• Homogeneous actions • Scenario writing, realism• Help• Clear understanding inside of training team of:

– Teaching goals– Pedagogic dynamics– Check-lists– Frames

Curriculum

• According to consensus inside the team• Can be written in a telegram-style• = Scenario of the scenario• Regular assessment• Regular improvement, re-writing, adaptation

How did we do?

• Assessments - feedbacks - corrective measures - re-evaluation

• Training evaluation is recognized as an important component of the instructional design model

• But there are no theoretically based models of training evaluation• Four levels of evaluation: trainee reactions, learning, behaviour, and

organizational results Kirkpatrick (1976, 1987)

• Application of cognitive, skill-based, and affective theories of learning outcomes to new methods of training evaluation.Kraiger, Kurt; Ford, J. Kevin;

Salas, Eduardo. Journal of Applied Psychology78.2 (Apr 1993): 311-328.

Recommendations, conclusion

• We are all humans• Anticipation: curriculum• Clearly define teaching goals, write scenarios• Put modulations in a certain realistic frame• Debriefing = crucial moment• Positive kindness, good judgement, psychological safe

environment• Adapt to trainee’s level and wishes• Give and get feedbacks• = plasticity around a solid structure…