Simulcast Journal Club March 2018 – PEARLS Before Snythe

Introduction :  

Simulcast Journal Club is a monthly series that aims to encourage simulation educators to explore and learn from publications on Healthcare Simulation Education.  Inspired by the ALiEM MEdIC Series, each month we publish a case and link a paper with associated questions for discussion.  We moderate and summarise the discussion at the end of the month in pdf and podcast format, including opinions of experts from the field. 

In order for the journal club to thrive we need your comments!  Some participants report feeling nervous about their initial posts, but we work hard at ensuring this is a safe online space where your thoughts are valued and appreciated.  To ensure this, all posts are reviewed prior to posting.  We look forward to learning from you. 

Copy of Journal Club

Title :  “PEARLS before Snythe 

It had been easier, Brad thought, when Dr Snythe had been focused on destroying his simulation program.  But with the publication of Brad’s improved CPR stats post implementation of the PICU Simulation Program, he’d been both confused and delighted to find the rival intensivist suddenly supportive of his work.  There had been, however, an unexpected catch. 

Snythe was suddenly excited about the educational benefits of simulation.  And he wanted in. 

While Brad had tried to maintain the fundamental premise as Snythe tried to negotiate both learning to debrief and learning to use his frontal lobe, he was ashamed to admit that his archenemy’s combination of enthusiasm mixed with concrete thinking was making him frustrated, and in some ways, downright snarky. 

“You’re getting there, Snythe.” He said after their latest debrief.  “But remember your debriefing molecule.  I felt like today you lacked a decent 3 phase structure, and it lead to a very instructor centred debrief.  It came across as a bit all over the place.” He paused and muttered under his breath.  “Kind of like your resuscitations.”. 

“I heard that!” snapped Snythe, “And I wasn’t going for your traditional model.  I’ve been reading a lot about PEARLS and I wanted to give it a try today.  I assume you haven’t seen it but they’ve just released a debriefing tool.”. 

He pulled out his tablet and showed Brad a crisp, blue and white cognitive aid. “Gotta get with the times, old friend.” He grinned.  “Wouldn’t want to come across as outdated and irrelevant.”.  He paused and grinned wickedly.  “Again.” 

Brad scowled.  The truth was he’d heard a lot about PEARLS in conversations with sim educators, but he’d never really ‘got it’.   Sounded like he’d better jump on the bandwagon though.  It had been a while since he’d felt motivated to read much sim literature, but nothing got his inner bookworm going like a good case of career rivalry. 

It was time to time to head to debrief2learn.  For knowledge…. and more importantly, for revenge. 

The Article : 

Eppich, W. and Cheng, A. (2015). Promoting Excellence and Reflective Learning in Simulation (PEARLS). Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 10(2), pp.106-115. 


In 2015 Eppich and Cheng released a new structure for debriefing that is practical, pragmatic and more flexible than some more traditional approaches.   Over the next few years they have released a number of papers to assist in translating their original landmark paper. 

For our journal club discussants this month, what has PEARLS meant for you? 

How have you found using the new debriefing tool? Or if you haven’t used it, check it out and let us know what you think?  The team behind it are keen for your input! 


References : 

Eppich, W. and Cheng, A. (2015). Promoting Excellence and Reflective Learning in Simulation (PEARLS). Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 10(2), pp.106-115. 



About Ben Symon

Ben is a Paediatric Emergency Physician. He is based at The Prince Charles Hospital in Brisbane. In 2014 Ben was the first Simulation Fellow for Children's Health Queensland, and assisted in the statewide roll out of the SToRK Team's RMDDP program. He currently teaches on a variety of paediatric simulation based courses on paediatric resuscitation, trauma and CRM principles. Ben has a growing interest in encouraging clinical educators to be more familiar with simulation research.

Leave a comment

Your email address will not be published. Required fields are marked *

11 thoughts on “Simulcast Journal Club March 2018 – PEARLS Before Snythe

  • Warwick Isaacson

    Hi there! I am an Emergency Medicine trainee in Australia who has just started in an education role that includes simulation-based training for medical students, nurses and ED trainees. I am incredibly fortunate to have Victoria Brazil as a mentor in this role and have been able to attend learning sessions introducing debriefing to the absolute novice.

    My first impression of debriefing is just how hard it is! What appears to be effortless for Victoria I find a minefield of poorly phrased questions, variable psychological safety and instructor centric dialog that misses key learning opportunities.

    Having now had the opportunity to lead a few debriefs I have found the PEARLS tool to be incredibly helpful primarily as a cognitive scaffold with which to structure the session. I feel that as I gain more experience I’ll then be able to layer more complexity from analysis section of the tool (ie, figure 2 of the article) into my approach.

    The other tool I have also found really helpful for a novice is the Debriefing Assessment for Simulation in Healthcare (DASH) instructor version. Using this for immediate self-assessment post debrief been great for identifying areas to improve.

    Having now dipped my toe into the field of simulation based education I certainly have a newfound respect for how much effort and complexity is involved!

    • Ben Symon Post author

      Hi Warwick,
      Thanks so much for dipping your toe into journal club as well, it’s great to have you along.
      I really appreciated you sharing your perspective on PEARLS as a new debriefer, as it sounds like it’s an extremely useful tool for you when starting out.
      How do you tend to use it in your debriefs? Do you have a physical copy or do you just sort of mentally hold onto the principles?

  • ben lawton

    I have to start by confessing I LOVE this paper. We have debated the values of debriefing scripts quite a lot within our group and the (grossly generalized) theme seems to be that novice debriefers find them helpful and more experienced debriefers find them overly restrictive. PEARLS really addresses that divide by providing broad structure with specific examples which the authors explicitly state are not intended to be used verbatim by all. As a clinician who really started doing education when I got to consultant level I find when judging a lot of educational theory I am overly influenced by face validity, as influenced by my own educational journey, and this has tons of it – it just all sounds so sensible! I (consistently with what I read) find that when debriefing novice learners there is often quite a strong need for, and learner interest in, more time spent on didactic teaching. When debriefing experts it feels more like steering a conversation while specifically trying to avoid using the position of pseudo-power that you get from facilitating the session to give undue weight to my own opinions about how things should be done. Most scripts I have come across do not allow for this variation in debriefing when using the same scenario with different levels of learner but PEARLS is great for this. I think there is an analogy between debriefing scripts and clinical guidelines in that the less expertise you have in a domain the more likely you are to follow the guideline to the letter. The best guidelines allow for that and act as a scaffolding rather than a cage and I think PEARLS is a great example of that. I guess I am a bit cautious that this is still not very well proven to be the optimal approach and really relies on “expert opinion” albeit with a very well described rationale rather than level 1 evidence. I am also undecided on what the effects of using the same debriefing structure during a day long course with multiple scenarios are, I’m not sure whether it would be better to use a variety of debriefing structures/techniques (which you can to a degree within the PEARLS framework) or whether there is actually an additional value in participants getting used to the pattern of the debrief as that re-enforces the expectation setting piece described in the paper. The other analogy that seems relevant is that of the structure we learn when taking a medical history at med school. That basically serves as a frame in which we learn to map out and recognize illness narratives which we label as diagnoses and learn how to confirm/manage. The more expertise we develop in a particular area the more shortcuts we start to take or adaptations we start to make to suit our own practice and experience and I think consistently using PEARLS is really helping me learn to recognize patterns in groups I am debriefing making the decision of which route I want to take through the analysis phase a bit easier. Another great choice of paper – thank you!!

    • Ben Symon Post author

      Hey B1, Thanks again for your comments and ongoing presence.
      I think your thoughts have helped me reframe my thinking around PEARLS. Particularly with regard to your comments about clinical guidelines becoming more easy to diverge the more experienced we become. I have to confess it hasn’t been a paper that has hugely changed how I approach debriefing, and interestingly this was the first case study I wrote where I really struggled to find the right frame to present it from. (and I’m dissatisfied with my results). From my conversations with friends and colleagues PEARLS is repeatedly praised as a particularly useful tool or guideline for the beginner debriefer. I was chatting with Bruce Lister about it and he said he feels like there’s “just so much bad debriefing going on out there that we don’t realise”, and how useful PEARLS is at providing a structure to people who are unfamiliar with debriefing and need support.
      Warwick’s thoughts regarding how useful he’s found it starting out demonstrates that really nicely.
      For me, while I feel like it hasn’t changed my practice hugely I think that it many ways it is an important acknowledgement that there’s more than one way to do this stuff, and that time availability, learning needs and patient safety all form important roles in how we approach a particular debrief. I wonder sometimes if the traditional 3 phase debrief (which is my favourite to participate in and to learn from), has become perceived as the only way to do things in some circles, and I think that limits us from innovating. Rapid Cycle Deliberate Practice for example, hasn’t translated as swiftly, while traditional debriefing models from the original principles continue to be promoted around the world.
      Interesting stuff!

  • Melissa Morris, MSN, RN, CPN, CHSE

    In my current position I am not able to actively debrief and I only get access to clinician educators to discuss facilitation of debriefing at the time of the simulation. As the program puts adjunct clinicians in the facilitator role , many times without any simulation experience and without development, I have found that the tool assists in quickly imparting some type of standard for facilitation of debriefing.
    I have also directed many healthcare educators new using simulation, and those who I have observed to have limitations in simulation debriefing to access PEARLS and further their personal development of simulation debriefing.
    I find the tool very helpful, and am grateful to have access to the site which can easily be shared with many healthcare educators who are utilizing simulation with limited introduction into the methodology.

  • @nickharveysmith

    Out of all the debriefing scaffolds I have tried (and believe me I have tried a lot) this has been by far the most useful not only for me, a fairly experience debriefer, but also for some of my colleagues who are less experienced. I like the fact that you can also use it for both experienced and novice learners too.

    It may also have uses outside medical simulation as I have been looking at it with simulation educators in the police to see if it’s adaptable for their use as they lacked a framework.

    In short – nothing but praise and for me personally a game changer.

  • Demian Szyld

    Many people consider me an “expert” debriefer… whatever that means… but thinking that I’ve been learning, practicing and perfecting Debriefing with Good Judgement so almost a decade, I feel that I can speak a bit from this perspective. First I want to agree with others who have stated that the paper is brilliant. I think it is well written and very helpful in clarifying various sub-mechanisms within the phases of a structured debriefing.

    While the authors propose that the approach is helpful for novices, knowing the authors personally, I read the manuscript as a description of various moves that very experienced debriefers can use in a debriefing situation. Jenny Rudolph, taught me that this is called a contingency model in the field of systems dynamics. So I recognize the moves described in the paper as option for the debriefer that can be activated given various situations. The tables do a good job clarifying this. Summary- I don’t recommend handing this paper to a novice and say: “go debrief”. Thought it has some scripts, this paper is not the place to start.

    Now, for some critique- I think my biggest area of concern is the move towards “Learner Self-Assessment” or the “Plus-Delta” move. My concern is focused on 3 pillars: 1) Dunning-Kruger effect (–Kruger_effect) and 2) the critical role instructors play in fostering reflection via feedback and asking questions and 3) a practical issue that remains unsolved- what happens when the learners list a Plus that actually describes a substandard performance, ie: we had very high quality CPR, we really nailed the rate of 60 compressions per minute! Suddenly the debriefer has 2 tasks, point out and correct the substandard performance in the sim and also the poor assessment based on incorrect knowledge.

    In summary, I think the paper is very useful. I think it follows from the tradition of and is well aligned with Debriefing with Good Judgment and offers good ideas and practical recommendations for debriefers wishing to think through and codify debriefing moves.