Simulcast Journal Club August 2016 – Debriefer Knows Best


Introduction :

Simulcast Journal Club is a monthly series inspired by the ALiEM MEdIC Series.  It aims to encourage simulation educators to explore and learn from publications on healthcare simulation.  Each month we will publish a case and link a paper with associated questions for discussion.  We will moderate and summarise the discussion at the end of the month, including exploring the opinions of experts from the field.

Journal Club

Simulcast Journal Club August 2016 – “Debriefer Knows Best”

The Case :

Cath was sitting enthralled in the SIM control room watching a heated argument occurring through the glass in front of her. All told it had been a fairly tumultuous sim with the team making a number of surprising decisions.

Despite the critical hypotension and positive FAST scan, the group had elected to take the patient to CT to find the source of his intra-abdominal bleeding. The airway doctor Dale had also nearly come to blows with the drugs nurse Madge.

As the case was going to wrap up soon, Cath began to map out her main discussion points for the debrief.   It was a shame she only had 20 minutes, there was so much to talk about. “I need to address the decision to go to the CT.  That patient could have died.” thought Cath. “Then I’ll acknowledge that blow up with Madge and Dale.  If they can’t communicate honestly with each other, there could be huge repercussions for the patient.

With her priorities arranged, Cath rushed to the debriefing room to catch the participants as they walked out.

I can’t believe I didn’t call a trauma respond!” whispered Dale to his fellow resident.  “I don’t even know how to activate it here.  What if I get a trauma on nights?

Cath’s heart sank a little, there was no way she was going to have time to address the trauma respond issue, she’d already identified more critical issues that the learners really needed to hear about.  Besides, she thought a little guiltily, Dale failing to call the trauma respond was the least of his problems. With a deep breath Cath turned to the group:

“So,” she said, “How did that feel?”.


The Article :

“Learner-Centered Debriefing for Health Care Simulation Education”

http://journals.lww.com/simulationinhealthcare/Abstract/2016/02000/Learner_Centered_Debriefing_for_Health_Care.5.aspx


Discussion :

As passionate instructors we often have strong opinions on what our learners ‘Need to Know’.  Simulation participants, on the other hand, may have an entirely different set of learning objectives that they have identified while being in the scenario. In this month’s article from Simulation in Healthcare, Cheng et al explore the continuum of teaching styles between ‘Learner Centred Debriefing’ and ‘Instructor Centred Debriefing’. In doing so they advocate for a more Learner Centred approach to debriefing, while still acknowledging that there are benefits to an Instructor Centred approach in certain circumstances.

 

Please comment below on your thoughts and reflections on the article.

    • Where do you think you sit on the continuum between Learner and Instructor Centered Debriefing?  Has reading this article changed your stance?
    • Do you find it challenging to relinquish control of the learning objectives to your learners?
    • Conversely, it may be difficult for some Learners to share responsibility for the debriefing outcomes! What strategies have you found useful to assist you in collaborating with your learners in the Simulation setting?
    • As clinicians, it can be hard to learn to critique an educational paper like this. What are your thoughts about the structure and methods of this article?

Reference:

Cheng, A., Morse, K. J., Rudolph, J., Arab, A. A., Runnacles, J., & Eppich, W. (2016). Learner-Centered Debriefing for Health Care Simulation Education: Lessons for Faculty Development. Simulation In Healthcare: Journal Of The Society For Simulation In Healthcare, 11(1), 32-40. doi:10.1097/SIH.0000000000000136


About Ben Symon

Ben is a Paediatric Emergency Physician at The Prince Charles Hospital in Brisbane and a Simulation Educator at Lady Cilento Children's Hospital. 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.


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26 thoughts on “Simulcast Journal Club August 2016 – Debriefer Knows Best

  • Ian Summers

    Ben, what at terrific idea. So given that you have asked a question, left a pause and then are waiting for someone to start talking to fill it (cough). My thoughts:

    The article is well worth reading and outlines some really useful strategies and pointers to reflect on where you sit and where you want to sit.

    The continuum of leaner centred vs instructor centred is an interesting one, and like all good questions it is probably best answered with the phrase “it depends on…”. I can certainly identify with many of the strategies outlined for maintaining learner centred debriefing. I often find myself with one group over 3 months, or alternatively one group intensively over 3 days of a course. A transition occurs from mid zone to higher learner centred over the course of time. By the end of a 3 day debriefing this course of high end specialists this can be very apparent. “What do you want to talk about?” or “Is there anything you want to see on the video?”. Sit back and stay silent. The art of course is finding the balance between one individual in the group with a strong agenda not in line with the main group. Not sure if the article really addressed this.
    I loved the fact that the authors did address the timing aspect of debriefing because this is a major influence of topic shifting, closing and pacing, especially any centre running two streams that cross. It would almost be an article in itself.
    So much of what you convey about giving up control necessitates skills in body language, tone etc. There is no point saying that you are sharing control if the first time someone disagrees with you your body language shows annoyance.
    Again that balance relies on knowing and understanding the knowledge gradient between you and the particular group, and working out whether they are after your expertise or exploring their own. Sometimes you are the expert, and the learners want your knowledge.
    ” I am an adult learner and I’m telling you I want you to tell me the bloody answer”.

    As I said at the start. It depends….

    Keep up the good work. Thanks. Hope this helps.

    Ian S
    @IanMeducator

    • Ben Symon Post author

      Thanks so much for your thoughts Ian, and thanks for being first responder!
      I agree that our learners are also on their own journey, and their abilities to identify and advocate for their own learning objectives will improve with experience.
      In contrast to your debriefing experience, I often work with a random group of learners who may never work together again, and sometimes with junior learners such as med students and junior doctors, I feel like maybe they are at more of a stage of pre-contemplation with their learning, and they don’t have the maturity to necessarily reflect appropriately on what they need to learn. It must be really satisfying to watch a long term group of learners transition ownership of their debriefing and reflection over a period of time.
      Cheers!
      Ben

      • ian Summers

        Ben and the simulcast team,
        Thanks. I am indeed fortunate and yes, it is satisfying. I suggest you try it on your more junior group too. Seems to work but with tweaks. They do know their knowledge gasps and are often very open about them. Others thoughts please? Also VB described this article as contentious. Why?
        Ian

        • Ben Symon Post author

          Hi Ian, I’ll let Vic speak for herself but I think for me I feel like sometimes the Learner Centered model is overly esteemed as the ‘ultimate’ in education in academic circles and certainly from a clinical standpoint, a lot of junior learners come with significant blind spots that they are completely unaware of. If I’m teaching a bunch of med students or adult emergency trainees about a paediatric emergency, there will be times where I’ve had to temporarily pause debriefing all together and move to a didactic model because the group is so uncomfortable and uncertain that they can’t work themselves through the clinical problem.

          This article takes a pro learner centered stance although it graciously acknowledges many of the benefits of didactic or instructor centred teaching as well. At the same time, when I read terms like ‘Sage on the Stage’ vs ‘Guide on the Side’ I certainly interpret (rightly or wrongly) an implication that the ‘Sage on the Stage’ is a slight object of derision or mockery. The terms may well have just been chosen because they’re catchy, rhyme and give a good idea of the concepts at hand, but I’ve learned a lot from instructor centered debriefing and teaching and I think in the junior learner who needs a baseline level of knowledge to begin reflecting upon, it can be very useful.

          I think as a clinical educator time pressure and lack of resources are also frequent demons to battle against, and maximising the team hitting their learning objectives for a specific simulation requires a less open ended approach.

          One of the tables also discusses cultural differences in debriefing, which I’d be interest in others’ perspectives on. My discussion with one educator from Hong Kong is that a lot of Asian learners will struggle with moving to a learner centred approach, being much more culturally comfortable being told ‘what the did wrong and right’.

          In summary, Learner Centred Debriefing appears to be a wonderful learning utopia, but I’m not sure it’s always actually achievable or appropriate to veer entirely to that side of the continuum.

  • Nick Argall

    Like any complex issue, there are all sorts of shadings and nuances to be applied. Different situations will call for different approaches, and judgement will need to be applied. Some additional things to consider (following up from my comment on Twitter):

    LEARNER-CENTRED DEBRIEFING REQUIRES MORE SKILL FROM THE INSTRUCTOR
    It takes a certain level of skill and knowledge to prepare a simulation, understand the events that are intended to take place, and to be ready to provide further information based on the plan. This level of skill can be quite significant, and this ‘baseline performance’ quite challenging to achieve. It takes a greater level of skill and knowledge to respond effectively to questions and concerns that are not part of the plan, for two reasons: the understanding of the simulation content needs to be wider and deeper (to cope with the various contingencies that may arise), and a parallel skillset (managing a learner-centred debriefing session) is also required.

    It’s not hard to think of someone who is a master of the subject matter being ‘pulled off course’ because a learner asks a question about a fascinating tangent, and then doesn’t leave enough time to attend to information that would have a bigger impact on performance outcomes. It’s also not hard to think of someone who doesn’t have a strong understanding of the subject matter, and is only able to address the content that is in the plan. Neither of these hypothetical instructors will perform well when attempting learner-centred debriefing.

    ADDRESSING THE LEARNER’S PRIORITIES LENDS LEGITIMACY TO THE INSTRUCTOR’S PRIORITIES
    If, as a learner, I have a burning question that I’m desperate to have answered, then I may have difficulty attending to anything that doesn’t obviously address my question. If my question can be addressed in a satisfying way, then I become more receptive to taking in other information. Also, learners have an intuitive understanding that learner-centred debriefing requires a greater breadth and depth of skills; establishing the instructor as someone who has that breadth and depth enhances their authority and credibility.

    LEARNERS SHOULD NOT ‘MAKE THEIR OWN MEANING’ IF THEY ARE BEING INSTRUCTED
    The paper includes the following statement in the ‘learner-centred’ column: “Instructor facilitates… allowing students to make their own meaning out of it.” In my view, this is flawed in a subtle but meaningful way. In general, a person who is equipped to establish the meaning of an event is equipped to be the instructor. Therefore, in an environment where the instructor is worthy of the title, they have a responsibility to ensure that students arrive at meanings which promote professional development. Failure to properly construct meaning is one of the leading causes of dysfunction in organizations – a well-intentioned but naive meaning for an event (eg “I need to work harder”) can undermine professional performance, while a more enlightened meaning can incorporate the instructor’s hard-earned wisdom.

    I’d much rather say that the instructor “Assists students to create meanings that promote their professional development.” The work of creating the meaning is a valuable skill in itself, and debriefing provides an opportunity for learners to practice that skill. However, it’s a skill that is most relevant to those who work unsupervised, or who supervise others; therefore, it’s unlikely to be worth a significant time investment outside of a leadership development curriculum.

  • Brent Thoma

    Great case Ben! And thanks for the shout-out to the MEdIC model 😀

    To address some of the questions directly:

    Where do you think you sit on the continuum between learner and instructor centered debriefing? Has reading this article changed your stance?

    I’m admittedly a huge fan of the concept of learner-centered debriefing. I actually tried to pursue this a bit from a scholarly perspective during my simulation fellowship and stumbled upon Self-Determination Theory (SDT). SDT is, in my opinion, a much more helpful way to consider the motivation of learners than ‘adult learning theory’ and is very much in keeping with learner-centered debriefing. In particular, the concept of giving the learner autonomy of the debrief is, at least from the perspective of SDT, more likely to motivate them than some other techniques. While SDT wasn’t explicitly discussed in the manuscript and I have not delved into the learner-centered literature, I suspect that it provides much of the support for this type of framework. Before I geek out too much, reading the article has, if anything, supported my stance and, if anyone has an interest in SDT, there’s more in our article which focused on a very different group of learners than this case (pre-clinical medical students rather than practicing clinicians): http://stel.bmj.com/content/early/2015/04/22/bmjstel-2015-000019

    Do you find it challenging to relinquish control of the learning objectives to your learner?

    I think that, with all things, balance is required. For example, in this scenario the instructor seems worried about being able to fit in time to discuss the trauma-respond that the learner seems to be prioritizing. However, I’ll note that in this case (and in many similar ones), I do not find that the item the learner is most interested in addressing will be time consuming to discuss. The learner’s questions regarding the trauma respond are fairly direct and if brought up in a learner-center style could (ironically?) be addressed with a very instructor-centered response (telling him how the trauma respond works). As that seems to be his main concern, I suspect that he will not mind if this issue isn’t delved into deeper by inquiring about why he didn’t activate the trauma. I also think that, if given the floor, the learners will actually identify the issues that the facilitator has also prioritized.

    Conversely, it may be difficult for some learners to share responsibility for debriefing outcomes! What strategies have you found useful to assist you in collaborating with your learners in the Simulation setting?

    As outlined above, I don’t think learner- and instructor- centered strategies are mutually exclusive. Advocacy-Inquiry is a debriefing technique that I think can allow the instructor to influence the true priorities of the learner.

    What are your thoughts about the structure and methods of this article?

    Methods, what methods? 🙂

    I believe the methods are mostly described in a single sentence: “The article is a critical reflection, review of the literature, and synthesis of discussions.” From one perspective, that could certainly be held against the article as it is unclear what specific search methodology and type of qualitative analysis went into building the article. However, I think the article was clear with its 5 objectives and they were each addressable in this commentary style.

    As a result, I do not think this article provided proof about anything. It did, however, provide a compelling background and argument that I suspect will inspire research protocols in the future.

    I enjoyed reading the comments so far and look forward to seeing more of these discussions. Congratulations on the launch of your site and watch out for the launch of ours (Debrief2Learn) in the near future 🙂

    • Victoria Brazil

      Thanks for joining in Brent, and thanks to others for interesting comments.
      I do think the article is contentious!
      For me the archetypes are laid out with a clear favourite by the authors- the LCT. The ‘critical reflection, literature review’has resulted in a fairly selective presentation of the evils of ICT 🙂 versus a superior LCT approach.
      The comparison with shifts to PBL in medical curricula is a prime example. In the article this is presented as evidence of the superiority of LCT approaches. However despite 22 years of outcome research the superiority of PBL over ‘traditional medical curricula has failed to be established.’

      That said, of course i agree that approaches that ‘nurture active meaning makers’are ideal. I just think that can still be achieved by a decent level of ínstructor control, direction and structure. (and if i am honest i think the authors mean that too) The comments and tables related to balance were the strength of the article for me.
      There are risks of LCT approaches – many along the lines of learners not knowing what they don’t know….and learners and instructors being influenced by what learners like, which may or may not be what’s most effective for their learning.
      So – as usual in debriefing – context is everything, and having the awareness and conversational skills to be able to match our methods to the situation is reinforced by this paper.

  • Cliff Reid

    This has been an incredibly timely and helpful discussion to read as our Sydney HEMS Induction Course Faculty has been agonising over optimal debriefing styles these last few days!!
    Thanks for a great blog and thought-provoking discussion

    Cliff

    • Jesse Spurr

      Thanks Cliff. Knowing the pace at which Clare’s mind works, I am guessing she has coming up with four or five potential options. Have you come to a collective stance on what is optimal for your setting? Induction/orientation is a tricky time for education – I tend to think of most scenarios as having dual intended learning outcomes – those for the participants (educational and constructive); and those for the facilitators/organisation (evaluative/diagnostic). In my opinion the debrief moves somewhat between completely learner-centred and completely instructor-centred depending on the weighting/criticality of the intended learning outcomes. Maybe a gross over-simplification, but a way for me to have my own mental model. I am learning so much from the responses to this Journal Club. Great work by Ben Symon to take this from email list to open blog format.

      • Cliff Reid

        We haven’t found the right balance yet but the point on the learner-instructor orientation spectrum needs to vary according to the phase of the induction, the experience of the participants, the learning objectives of the scenario, and the performance of the team. It’s further complicated by the fact that a single team is composed often of a total prehospital novice with a lifelong prehospital expert, and if they’ve both demonstrated learning needs we need to find the best way to debrief quickly and provide it in a very short time frame. We have deliberately opted for more sim time at the expense of debrief time, anathema to expert doctrine, but we want the novices to get hands on in an immersive setting as much as possible.

        Hence the agonising. This is currently the most painful and difficult part of an otherwise very painful and difficult but amazing course to be part of.

        • Ian Summers

          I am learning a great deal from the comments of all. Thank you. Balance, and “all things in moderation” seems a consistent theme. Ideally we would have a mastery of a variety of techniques and be able to use the one most appropriate at the time, flexing across the continuum of lCT vs LCT to suit.

          Cliff, that’s an interesting and challenging set of debriefing construct requirements you have come up with. I look forward to hearing your solution because you face the same set of challenges we are grappling with at a reconstruct of ACME (Advanced and Complex Medical Emergencies) so we will probably have an overlap of solutions. What sort of time do you have in mind to debrief a complex scenario? How much consistency do you want between the style of individual debriefings and how much will it change between start and end of the course or between individual facilitators?

          We often evolve over the course but there is a variety of techniques being used which has its strengths too in that the participant’s get a exposed to a variety of style (although hopefully not of quality).

          To what extent (if any) do you want the participants to understand the debriefing techniques being used so that they might be able to use them later in your stressful pre-hospital setting where I assume they might want tools to run their own debriefing? In which case +/delta works for many of your objectives, certainly speed, and higher end learners can drive the process allowing your pre-hospital experts to shine, especially towards the end of your course after “meatier” debriefs have been used.

          Anyway good luck and please let us know what you come up with.

          • Cliff Reid

            Thanks for your thoughts Ian
            I don’t have well thought out answers at this stage but you have given us more food for thought. Would love to hear more about the ACME process.
            Cliff

          • Ian Summers

            Hi Cliff,

            ACME https://www.acem.org.au/Resources/Educational-resources/ACME-Course.aspx
            It’s an ACEM sponsored/owned 3 day course high fidelity Sim in ED environment with focus on human factors, complexities of ED environment, CRM as well as procedures.

            Participants ED physicians, final year registrars and senior emergency doctors.
            Mainly run at St V Melbourne, Auckland and Waikato Centres.

            Is ripe for the picking for you to come and observe/assist and help us redesign! Next one Melbourne Dec 7-9.
            All the same challenges as you are describing hence my interest in your dilemma and solutions. Brilliant fun to be part of faculty as we always learn heaps.

            My point about teaching high end participants some debriefing knowledge and making a structure overt at some stage (I choose +/delta for this part) is that we are exposing this very senior group to repeat exposures of debriefing often for the first time- potentially a useful experience triggering reflection on if/how they do it after an event themselves. It also engages the expert who might switch off from the “doing” but reengages with the “teaching/caring” side. Seems to work, strong feedback at lunch time chats.
            If you want to discuss and pass on your ideas give me a call through St Vincent’s switchboard. Would love to hear.
            Ian

          • Victoria Brazil

            Hi Cliff
            This work on rapid cycle deliberate practice might also help relieve you of too much doubt about focused, instructor centred approaches for some learning objectives

            As they say

            This novel method utilizes direct feedback and prioritizes opportunities for learners to “try again” over lengthy debriefing.

            Would seem suited to some of what i understand of your context?

            all the best
            vb

        • Nick Argall

          I think it’s very difficult to address the learning needs of experts when there are novices present. Feedback relevant to an expert’s performance can be counter-productive if attempted by a novice. To some extent, there’s an amount of value in modelling ‘how to help novices improve’, but that’s tricky as well, because ‘having concerns about novices’ is a tricky topic to raise in front of novices.

          Part of the work I’m doing is investigating ways to separate technical training & practice (how to perform a procedure) from contextual training & practice (how to talk about a procedure). Our initial work has focussed on juniors and residents in an emergency department – we’ve found a way to put the simulation focus onto coping skills and communication strategies. This has been successful enough that we’re now ready to look at the needs of people entering a consultant role.

          • Cliff Reid

            Thanks Ian. Look forward to catching up.

            Nick- cool stuff. Sounds like really useful training.

            Vic – funny you should say that… We introduced rapid cycle deliberate practice (based on that paeds paper) in August 2014. Our first round of sims (on day 2 of our course) follows that structure, before we then go into full immersion. I presented something on it at the London Trauma Conference in 2014 in this talk: https://sydneyhems.com/2015/01/16/prehospital-trauma-education/ – I have a bit of a rant about debriefing at the 31’39” mark if anyone’s interested in fast forwarding to there.

          • Ben Symon

            Thanks for linking your ‘rant’ Cliff, I really enjoyed it and couldn’t agree more with the importance of knowing where your learners are in their journey and adjusting debriefing appropriately. A transition from rapid cycle to advocacy and inquiry over a few days of a course sounds like a great way to follow that journey from skill acquisition to reflective practice.

            Another educator was discussing this article the other day, and they mentioned the ‘Hidden Curriculum’, which I think is a really interesting point regarding Learned Centered Debriefing. There is this fundamental dichotomy between a well designed Simulation with clearly defined learning objectives, and then asking the learners to come up with their own after participating in the sim. Does this not set up a little bit of subconscious ‘guess what I’m thinking’? If they hit different learning objectives all together, has my course delivered on its aims? Sure they might have learned something, but if it’s not what they paid to learn, am I just providing a platform for reflection about medical practice in general?

            For example, a Paediatric CRM course I teach on aims to focus on discussing communication during resuscitation. The cases are designed fairly simply in an attempt to minimise a focus on medical management, but invariably a large part of each debrief is devoted to differences of opinion on medical management. At the end of the day, I feel like the course sometimes isn’t hitting its goals as well as it could be. They came to learn about CRM, but they walk away wondering if they should’ve intubated that asthmatic. I’m not sure that’s a job well done, and trending more towards an Instructor Focused Debrief may be needed.

          • Nick Argall

            Cliff – Thanks, I agree completely with your ‘rant’ (although I found the label misleading). There is a place for debriefing, but your stop-pause-rewind seems like an excellent way of handling something where the correct behaviour is well understood by the instructor. (Whereas, in your ‘consultant team’ example, there might not be a ‘correct behaviour’ that can be responsibly imposed. So, as you say, extended debriefing may be appropriate.)

            Also, thanks for putting up the video – as a trainer, I loved your anecdote about the preschoolers. Know your audience!

            Ben – Your point about ‘The Hidden Curriculum’ is excellent. Every time an instructor plays the ‘guess what I’m thinking’ game with me, I find myself angry. If you (the instructor) think you know the answer to a question, then I think it’s normally best to give the answer. While facilitated exploring can be useful, excessive reliance on an individual tool (such as facilitated exploring) is always a mistake.

            You also touch on ‘simulation as a tool for training’ versus ‘simulation as a tool for exploration’. If you have specified learning objectives, you have to know what you’re going to deliver, you have to have a plan for how that’s going to happen, and you have to use the plan to make sure it happens. (This doesn’t always mean ‘follow the plan’.) If your objective is to explore (perhaps in order to identify the most pertinent learning objectives), then a much more learner-centred approach becomes relevant.

            When it comes to teaching communication, I think that my lack of medical competence really helps me. It is impossible to draw me in to a highly-technical tangent regarding a fascinating medial oddity, because I don’t understand anything beyond a second-year undergraduate level (which is when I dropped out of health science). Micah Endsley reported a similar phenomenon – much of her ability to improve cognitive performance in pilots came from the fact that she couldn’t fly a plane & therefore she had a laser-like focus on cognition.

            So one option would be ‘bring in a communication expert and make sure they focus on communication’. Alternatively, greater discipline (most sustainably achieved via more structure – ie, yes, instructor-focussed) is what you’ll need.

  • Shannon Scott-Vernaglia

    Sorry–this was originially sent by email when I was too clueless to come here!
    Shannon
    —–
    Once again a great article. Thanks!

    So, I was initially most struck by the idea that while we all might ascribe to being learner-centered, the hidden curriculum may actually tilt much more to instructor-centered. We’re at least really working to try to achieve a balanced approach, largely because of the key issue in the top of Table 2—time. To be completely learner-centered would require more time than we have in our specific program. We do however, as they suggest, really try to use the reaction phase to guide our learner-centered aspects of the debrief. Part of that comes back to discussion from last month’s article and whether or not participants really talk about “feelings” or, we have found, are more likely to identify the content they really want to discuss. We actually jot those down on a board to make it clear that we’re coming back to them. This was in response to feeling like just asking for feelings, but then not immediately addressing the content issues raised, left us all hanging. We then add to that list some ICT items we’d like to cover.

    One thing that I think promoted LCT during the debrief is to have folks actually look stuff up that they wish they knew during the sim. We don’t have easy access to computers where we do our debrief, but they do have their code and PALS cards and we encourage them during this “activated learning” phase to actually go find the dose of naloxone for example if they are frustrated they couldn’t find it during the scenario. And we’re certainly working hard to get curious and explore learners’ rationale as noted.

    I think using the “take aways” in the summary phase not only ends in a LCT fashion, but it also helps you as the debriefer to realize if your own take-aways match or not. I always find that a useful piece of feedback to me as an educator.

    Lastly, one thing that has helped us try to be learner driven during the debrief is knowing that we have a one page “key learning points” and an associated article for each case. These are emailed out to the participants after the sim, in the hopes that they are particularly motivated to read more at that time. It frees the instructor from feeling bound to have to cover topic A, B, C, and to instead focus first on topics the participants raised, then adding any key other parts they observed and perhaps not covering everything.

    As I say many times in many setting, moderation is the key to many things in life. So it is, I think with the balance between LCT and ICT. I appreciate the reminder that even when we feel balanced, we’re likely tipping toward ICT and that mindful tipping the other way is most likely to keep the see-saw balanced.

    Looking forward to others’ thoughts
    Shannon

    • Ben Symon Post author

      Thanks so much Shannon, I love the idea of capturing the learners ‘acute motivation’ post sim by sending out appropriate learning resources in the week after simulation. Do you get much feedback that they have read it?

  • MC Yuen

    The article is an excellent article for enhancing debriefers’ skills in conducting effective simulation based education. It clearly delineates the difference between and the advantages of using instructor-centered teaching and learner- centered teaching.

    The authors listed out three important factors, namely time, knowledge and experience of learners, and national culture, a debriefer should bear in mind in achieving a balance between Learner-Centered Debriefing and Instructor-Centered Debriefing.

    As a Chinese, I would like to add my opinion on the cultural factor that will affect the integration of Learner- and Instructor-centered debriefing.

    Generally speaking, in the Chinese culture, we are taught to respect our teachers and revere their teaching. Therefore, we are quite “obedient” in following the teaching designed by our teachers and seldom express our needs, let alone of challenging our teacher to meet our need. Our obedience is nearly absolute when we are fresh and inexperience.

    Even when there is a clear discrepancy between our learning needs and the teacher designed learning objective, learners will just keep silent to show respect to our teacher. This sort of behavior will jeopardize the flow of the debriefing process and the result of which is a monolog type of teaching from the instructor. But in our heart, we want our teacher respects our learning needs too.

    I found in the article there might be several ways which help address this cultural issue, they are as follows:
    First, the establishment of the basic assumption (everyone participating in the simulation is intelligent, capable and is trying to do their best to learn and improve) helps create an environment conducive to learner-centered teaching. The instructor should point out learner should express their needs to more the learning more effective.
    Second, in the reaction phase of the debriefing, the instructors should verbally acknowledge topics on the learner agenda, this validates these learning needs and further empowers learners to take responsibility for their own learning.
    Third, the instructor should summarize the learner agenda before transitioning to the analysis phase, instructors assure learners that these topics will be explored, thus engaging the learners in preparing for reflective learning. By doing so, the instructor can demonstrate to his learners that he treasures his learners’ input in the learning process.

    I think the about ways help learners know that their instructor also respects their learning need. The above techniques might help break down the cultural wall and preventing the debriefing from becoming an instructor’s monolog. I will try them in my next debreifing.

    Thanks Ben for sharing this interesting article.

    • Ben Symon Post author

      Thanks for your thoughts MC, I was really fascinated when we originally chatted about the cultural differences in asian cultures and western cultures in debriefing practice. What really struck me by your comments was that you mentioned that culturally your learners take a much more submissive role in the debriefing environment, but that you feel that actually they would very much like to be more engaged. Do you find with regular simulation that your learners open up? Or are the cultural boundaries so strong that this makes your learners uncomfortable and disengage?

  • Callum Thirkell

    My response comes from a paramedic lecturer teaching primarily 1st and 2nd year students (but also a bit of 3rd year). I work as an Intensive Care Paramedic for Wellington Free Ambulance and teach at Whitiriea NZ.

    My feeling is that we slowly move up the continuum from learner to instructor centered as they progress through the degree on a bit of a curve rather than a linear increase.
    1st and 2nd year are heavily instructor centered partly because they have very little knowledge but also little context.
    We also have the complication of using simulation as a key summative assessment for each semester. Therefore as you can imagine there is a significant focus of the students on our opinion!

    We generally structure a practical/simulation ‘push’ after a few weeks covering relevant theory. The students then take part in 5 very structured sessions with a 6:1 student:tutor ratio. They do one and observe 2 simulations each session. Each simulation has a specific learning objective ranging from a specific treatment pathway, a differential process etc etc so they learn just as much observing the other simulations. While we sometimes use a LCT based on discussion initiated by our students the ICT model dominates.

    Our 3rd year class is actually run by distance with two block courses per semester. Due to resource constraints scenarios are often actually run by and debriefed by students. Is this the extreme end of LCT if it doesn’t involve an instructor? I’m still unsure of this approach and whether it really is appropriate for pre-employment students.

    I’m not convinced the LCT approach is the better approach and it really depends on the who the students are and what they are trying to achieve.

  • Ben Symon Post author

    Thanks to all for your comments, I am currently completing formatting of our summary for the month.
    Please continue to feel free to comment, however further contributions won’t be included in our pdf summary.