2025 VASSA

Heather Anne Noland, MED, CHSE-A, CHSOS, FSSH

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Centra Health in Lynchburg, VA

Clinical Simulation Outcomes Specialist

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Objectives:

Janice Palaganas, 2016

“The quality of learning achieved during debriefing depends on the facilitation skills of debriefer.”

“Failing to address oversight or misconception validates the error.”

Leadership 101

Brendan Wovcho @ Ramsey Solutions

Foundations in Simulation Practices

• Psychological Safety
• Learner-Centered approach
• Facilitating the conversation
• Probing questions to engage in critical thinking.
• Debriefing setting vs individual setting

Foundational Resources

• Healthcare Simulation Standards of Best PracticeTM
• SSH Certification Standards
• SSH Accreditation Standards
• ASPE Standards
• Professional Standards

Educational Theories

Zone of Proximal Development (Vygotsky)

Social Learning Theory (Bandura)

Adult Learning Theory (Knowles)

Experiential Learning (Kolb)

Mastery Learning & Deliberate Practice (Erikson & McGahie)

Reflective Practice (Schon)

Inform our practice.

Experiential Learning Theory

• Learning is a continual process:
• Concrete Experience
• Reflective Observation
• Abstract Conceptualization
• Active Experimentation

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• The learner needs to be actively involved.

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Adults learn by critically reflecting on experience and learn by changing one’s frame of reference.

Transformative Learning Theory

Disorienting Dilemma: causes the learner to question their existing beliefs and perspectives.

Jack Mezirow

Critical Reflection: examining one’s assumptions, beliefs and experiences in a thoughtful way.

Frame of Reference: established way of thinking.

Perspective Transformation: where an individual revises their frame of reference in order to adopt a new one.

Feedback 101

Verbal: words we use

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Para verbal: how we say the words

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Nonverbal: body language, eye contact, body positioning, gestures

Let’s Talk about Learners

Learner-Specific Factors

Inherent affect

Personality

Previous experiences/biases

Learner persona

Not open to feedback

Simulation-Specific Factors

• Design of simulation
• Execution of simulation
• Lack of engagement and preparation.

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Faciliator-Specific Factors

Inherent affect

Personality

Leadership/Mentorship skills

Learner biases

Previous Experience

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Difficult Feedback Situations

• Uncomfortable with confrontation
• Believe they will improve on their own
• Lack of time to deliver the feedback
• Uncertainty of own knowledge base
• Waiting for a pattern to develop
• Prevent problem before it occurs**

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So what do we do about those factors?

Keep the Framework Simple and Set Expectations!

• Keep, Start, Stop
• KEEP: Statements about effective behaviors that should continue
• START: Suggestions about effective behaviors the learner should start doing.
• STOP: Suggestions about ineffective behaviors that the learner should stop doing.
• Lay the foundation regarding feedback before it happens.
• Create a culture of feedback
• Encourage and model self-reflection

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Setting the Stage for Feedback

• Preserve Psychological Safety
• Establish a regular place and set expectation
• Make it clear that you are offering feedback
• Ensure everyone understands educational goals, expectation and roles
• Short, timely bits (not apart of overall evaluation)
• Pulse check: do not deliver feedback when emotions are running high
• Goal: competency at level of education and experience

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Mezierow’s Transformative Learning Theory

Initial State:

Individuals operate within their established frame of reference, making sense of the world based on their existing beliefs and assumptions.

Trigger:

A disorienting dilemma or challenging experience disrupts this equilibrium, causing the individual to question their current understanding.

Reflection:

The individual engages in critical reflection, examining the source and validity of their beliefs and assumptions.

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Mezierow’s Transformative Learning Theory

New Understanding:

Through reflection, the individual develops a new, more inclusive, and more accurate understanding of the situation.

Integration:

The new understanding is integrated into the individual’s frame of reference, leading to a change in perspective and behavior.

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Hallmarks of this theory:

Prioritize importance of critical reflection

Challenge beliefs and assumptions

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Debriefing Feedback Opportunites

The Defensive Learner

•May create the most difficult debriefing session.

•Defensiveness

•Destruction

•Put individuals in a closed-minded state

•Create an aura of contention

•Leave individual(s) feeling unheard, misunderstood, frustrated and resentful

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Proactive Strategies

Prepare Learners

Clear expectations

Acknowledges limitations

Commitment to respecting learners

Foundation of psychological safety

Feedback Environment

Body Language

60% nonverbal communication

Eye Contact

Speaking & Listening (results)

Reactive Strategies

Body Language

Adapt to the situation

Eye Contact

Scan and Land (group feedback - quiet)

Redirection (aggressive)

Silence

Sit in it, allows for reflection

Rephrase question

Directive Questioning

Quiet/disengaged

Focus off dominant learner

•Relating to behaviors, feelings or attitudes of others to a societal norm (Gallagher, 2009)

•Build trust, calm fears and help with coping

•Defuse emotional situations

•Not approval, but understanding

•Must be genuine

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Example:

“That was a complex scenario. Most groups with a similar experience would have equally felt overwhelmed”

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•Recognition and acceptance of another person’s thoughts, feelings and behaviors as understandable

•Does not imply agreement/approval

•Regulating strong emotion

•Building self-identity, relationships, understanding and effective communication

•Confirms educator is listening and learner perspective is important

•Helpful when learners become fixated

Example:

“I hear what you are saying. The manikin’s heart and lungs sound artificial and can cause you to question what you heard.”

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•Widening the discussion to involve more learners or to incorporate another specific source of information.

•Uncovers a greater number of perspectives leading to a richer discussion.

•Incites creativity in problem solving, broadening wisdom and resources of the larger group.

•Helpful with disengaged learners, emotional or defensive learners or when one learner is dominating discussion.

•Can be used when learner challenges the information provided by the educator

•Incorporating clinical practice guideline (outside source)

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Example:

“I sensed a lot of tension around determining the step of intubation, did anyone else on the team sense the tension?”

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•When conversation becomes derailed

•Managing hot topics

•Naming/labeling the issue at hand so that the conversation can be refocused on the difficult issue.

•By explicitly naming the “elephant in the room” and previewing the conversation around it, the educator can introduce topics the learners felt uncomfortable bringing up on their own.

•Fostering discussion, reminding of ground rules to promote a safe conversation.

•May required generalization or normalizing, to encourage other perspectives

Example:

“It seems to me as if there are very strong viewpoints on what to communicate to the patient’s family member prior to giving adenosine and it is affecting our ability to have a balanced discussion around this issue right now. This is a very tricky situation. Let’s look closer at this issue of communication with family members and see if we can come up with a viable solution.”

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Group Practice

During a simulated code blue simulation Silent Sally was pushed out of the way by Dominant Derrick. This was Sally’s first experience in simulation and you have noticed that when she is uncomfortable she resorts to silence. Derrick is outspoken and has prior clinical experience as an EMT, it is important to him that he feels validated in class. Derrick pushed Sally away from the patient when she failed to start compressions. How would you craft your feedback to Sally, Derrick and the rest of the team?

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Role-Playing with Feedback Strategies

Volunteers to play a role in a transformational feedback opportunity.

References

Cheng, A., Grant, V., Huffman, J., Burgess, G., Szyld, D., Robinson, T., & Eppich, W. (2017). Coaching the debriefer: Peer coaching to improve debriefing quality in simulation programs. Simulation in Healthcare, 12(5), 319-325.

Edmonson, A.C. & Smith, D.M. (2006). Too hot to handle? How to manage relationship conflict. California Management Review, 49(1), 6-31.

Grant, V.J., Robinson, T., Catena, H., Eppich, W., & Cheng, A. (2018). Difficult debriefing situations: A toolbox for simulation educators. Medical Teacher, 40(7), 703-712.

Loomis, A., Thomas Dreifuerst, K., & Sherraden Bradley, C. (2022). Acquiring, applying and retaining knowledge through debriefing for meaningful learning.

Palaganas, J.C., Fey, M., & Simon, R. (2016) Structured debriefing in simulation-based education. American Association of Critical Care Nurses, 27(1), 78-85.

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