Simulcast Journal Club March 2019


Introduction :

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

The journal club relies heavily on your participation and comments and while it can be confronting to post your opinions on an article online, we hope we can generate a sense of “online psychological safety” enough to empower you to post! Your thoughts are highly valued and appreciated, however in depth or whatever your level of experience. We look forward to hearing from you.

Journal Club (4)

 

Title : “How to Host a Debrief”

Nimali pulled Nitin hastily into the supply closet and shut the door.

“The phone towers are down.” She whispered. “The roads around the education centre are flooding from the hailstorm and the police could be hours away. We’re stuck here surrounded by floodwaters with our entire simulation faculty, the corpse of a particularly sarcastic paediatric intensivist and a tea room stocked exclusively with International Roast Caterer’s blend.”.

Nitin winced. “There’s only one thing to do in a situation like this.”

Nimali nodded sagely. “We’re going to debrief the shit out of it. If we don’t work out who the murderer is by the time the cops arrive, hospital executive is going to find out what’s happened and they’ll close down our whole program.”

A flash of fear went across Nitin’s face. “If we do this we need a game plan, Nimali. This isn’t like other debriefs : Catherine’s crying her eyes out even though she hated Snythe, Brad’s frantically washing blood off his palms Macbeth style in the change rooms and Jacob has enough extraneous load on him just trying to stop Jessica live tweeting from the crime scene. We don’t exactly have experience crime solving, and while you’re debriefing, we’ll need to be checking for the clues in people’s statements. After all, you and I were the only ones not on campus when this happened.”

Nimali thought for a few precious seconds. Nitin’s heart still gushed at her ability to stay calm in the most horrific of crises. Crime solving, it had to be acknowledged, looked good on her.

“OK.” Said Nimali. “Here’s what we’re going to do. I’m going to ask everyone to help me make some coffee in the tea room. You go get Brad and help him move the body out of the debriefing room and into one of the supply rooms. There’s no way anybody will be able to focus with Snythe still in there.”

Nitin nodded solemnly.

“Once the body’s moved, I’ll take us all into the debriefing room. We’ll calm down Catherine, keep Jacob and Jessica engaged in the conversation and away from their social media. Brad used to work in forensic pathology so we’ll use him as our expert in the room, and together we can start piecing together what happened.”

Nitin smiled. “OK we got this. And to help with the germane load of it all, I’ll give you feedback with the DASH Serial Killer Version.”

Nimali kissed him quickly on the cheek. “You gotta give them credit,” she said wryly. “There really is a DASH for everything.”.

The Article (open access via the link) :

Fraser, K., Meguerdichian, M., Haws, J., Grant, V., Bajaj, K., & Cheng, A. (2019). Cognitive Load Theory for debriefing simulations: implications for faculty development.

Discussion :

 

When faced with learning to debrief, facilitators experience a wide variety of different types of cognitive load.

In this month’s article, Fraser et al break down cognitive load theory for educators, and provide sensible and practical interventions to optimise load when learning a new skill.

 

For our journal clubbers this month : What sort of cognitive strains do you find particularly challenging? How does this paper assist you in both simulation delivery and simulation design?

 

References :

Fraser, K., Meguerdichian, M., Haws, J., Grant, V., Bajaj, K., & Cheng, A. (2019). Cognitive Load Theory for debriefing simulations: implications for faculty development.

 


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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24 thoughts on “Simulcast Journal Club March 2019

  • Susan Eller

    Okay – still laughing at the DASH serial killer version.

    When I was reading this paper, it took me back to doing simulations for new patient care hires several years ago. We had some new nurse educators who had gone through our instructor course, but still struggled their first few times at solo debriefing – even after our apprenticeship training period. One of the things they found most helpful was a debriefing guide: phases of debriefing, a script modified from Eppich & Cheng, and some potential debriefing topics for the scenario based on our previous experience with new nurses participating in the same scenario. It was just a guide, but somehow having that in writing helped some of them. A cognitive aid for debriefing. I also was there with them the first few times – first as a role model, then a co-debriefer, and eventually just as a resource.

    One of the other things pertinent to cognitive load is that we were working with an electronic tool to engage the passive observers of the scenario. The medical students, residents, and new nurses did well with the new tool. When debriefing, David Salzman excelled at managing his own cognitive load with the tool and the learners’ responses. Some of our more seasoned educators were overwhelmed learning the electronic tool, and it was taking away from their ability to conduct a rich debriefing. We switched to a paper version of the tool, and the nurse educators were able to have much richer discussions with their participants during the debriefing session.

    I do agree with the article in that co-debriefers are an amazing tool – after you have developed a rapport. I have been fortunate to debrief with some experts. That also adds to my own intrinsic load, as part of my attention is spent worrying about how I am being perceived/rated. I find that once you have established some ground rules/guidelines, it allows me to feel much more comfortable.

    • Benjamin Symon

      Thanks so much for these tips Susan, and for coming along.
      It sounds like you’ve watched many a novice on their journey to mastery, and some of the tools outlined in this article have been useful for your colleagues.
      Can I ask, has it changed the way you teach how to debrief as well?

      • Susan Eller

        I think one of the things that I try to teach new debriefers is that cognitive load exists in debriefing. I can’t tell you how many times I will hear new facilitators say they didn’t realize that it was challenging. So many times they are trying to anticipate answers and formulate the next Pulitzer prize winning question, that they can miss profound insights that come from what the participants are saying. If they can off load some of the cognition by having an aid – that is great. The cognitive aid should also say “be present – listen to the participants. It is okay not to address every single thing in debriefing as it is usually not a one time event.”

        (Susan now jumps down from soap box 😉

        I agree with Ann – it is so helpful to receive feedback on your debriefing when you are a novice AND continuing. Getting meaningful feedback can also decrease your cognitive load.

  • Ann Mullen

    Thanks Ben for another great topic. I am happy to see that CLT is being discussed when planning our programs, and the cognitive load of the debriefers is an important consideration.
    This article had several good tips for managing this challenge. I appreciated the point that co-debriefing can be a strategy to decrease the burden, but can also increase the load. I have certainly been struck by imposter syndrome while working with esteemed colleagues, and I know that I am not the only one to feel that way!
    Selecting and prioritizing topics for discussion can be overwhelming, and this was described in the paper as intrinsic cognitive load. I think that this could be compared to a clinician learning to do a history and physical exam. In the beginning, we rely on tools and cognitive aides, and with experience and feedback, we know how to do that with little mental effort. Debriefers need clear learning objectives, a vision of ideal performance and cognitive aides to support them. Just as a preceptor gives feedback to a trainee, debriefers need to have ongoing support while they hone their debriefing skills.

    • Ben Symon

      Hi Ann,
      It’s so lovely to have you again this month after your epic contributions in Feb.
      It’s interesting that you mention imposter syndrome when working with esteemed colleagues, I agree you are not the only one who feels that way!
      I really find PEARLS a useful tool to give to colleagues learning debriefing. We’ve recently started training our nursing staff in Children’s ED to run our In Situ Debriefings, and so far PEARLS has been a good scaffold to hang on to for them.

  • Jenn Dale-Tam

    Hi Ben,

    If Nimali and Nitin can solve the murder of Snythe via a debrief, excellent! Simulation educators can moonlight or have a second career as detectives, though, in essence as debriefers that’s what we are.

    I am a devotee of Cognitive Load Theory (CLT). I find it straightforward to understand and easy to apply. It’s one of my “toolbox” theories for instructional design. I have not really reflected on my actions as a simulation educator using CLT specficially. Let’s give it a go.

    Employed as a staff development educator I have the joy of working with a core group of learners progressing from novice to expert or anywhere in between during the learning journeys of their careers. During simulation sessions with these individuals I initially struggled with the intrinsic load of psychological safety of the healthcare professionals as a novice debriefer while managing the extrinsic load of video technology. During the pre-briefs the tension would become palpable with the mention of secured video recording to use during the debrief. This increased my anxiety as I wanted the experience to be a good one for my colleagues and learners. During the debriefs, being a solo debriefer, the video technology never seemed to work right, many times I would have to ask the sim tech to set it up for me. This in of itself is disruptive to the debrief adding to my extraneous load while taking up my germane load. The schemas just would not form on how to use the videos efficiently and I was so focused on the needs of my learners’ psychological safety. Fast forward 12 months I decided to trial not using the video during the debriefs. It was like a weight had been lifted from my shoulders and the learners were more relaxed in the debrief. After a small literature search, the evidence appeared inconclusive for the use of video during debriefs so I decided not to use them anymore. The learners also stated they preferred not using the video during the debriefs
    Table 1 in the Fraser et al article is a beautiful summary of the cognitive loads experienced by simulation educators along with mitigation strategies. One of the most powerful tools I was introduced to by my simulation mentor was the PEARLS debriefing framework. This decreased my intrinsic load while managing the extraneous load of facilitating a debrief which is now the schema in my brain for debriefing.

    In summary this is an articulate article that is an essential read for new debriefers and simulation faculty development educators. Having not known about CLT until a few years ago, it would have helped at the beginning of becoming a simulation educator. Many of the strategies suggested in the article I employ now, but have had the privilege to be mentored and be part of a simulation fellowship where much of this was taught.

    Thank you for discussing this.

  • Zachary Buxton

    I want to start off by indicating that Ben as a co-worker and novice in the debriefing world I felt a strong pressure to get involved in the JClub discussion after seeing your tweet seeking discussion points. I was on the bubble but after reading the about Nimali and Nitin’s loss of cell tower connection (GASP!) I just could not leave the Murder Crew hanging.

    This article is particularly timely for myself as a novice who has just begun to step out on my debriefing journey. I appreciated some of the strategies put forth in the paper and also was very pleasantly surprised to see some I have picked up through osmosis. This is the benefit of having the opportunity to observe some absolutely incredible co-workers in action I suppose! (Not pumping Ben’s tires alone – I am surrounded by phenomenal debrief guru’s at both of my respective simulation roles!)

    In particular your suggested that, “the potential intrinsic load of difficult medical content can be reduced by inviting a subject matter expert to attend the debriefing” really spoke to me as a novice debriefer. I had an opportunity recently to act as lead debriefer for a course which would stretch me in terms of my clinical expertise if I were a participant and the idea that I would lead the debrief sat with me about as well as that trocar in Sneed’s left ventricle. I saw “the note” flash before my eyes “WheRE IsYoUr SAfE ConTainER NoW?” but thankfully I had in my co-debriefer an ED consultant as a subject matter expert. We had a chance to huddle prior to the debrief and decided I would preview the structure and expectations whilst she would debrief the clinical actions and I would close off the CRM and recap the debrief. The ability to wipe the cognitive load of the clinical subject matter enabled me to focus on other aspects of the debrief and pull together a reasonably good effort.

    I also had a great opportunity in that two of our staff faculty with a great deal of debriefing experience were then able to provide feedback on their observation of our session. I thoroughly enjoyed the feedback despite the added stress of having my educator and director observing our debrief. The value of this feedback honestly cannot be overstated. Although I am not certain I would have preferred my first Debrief of the Debrief to be done by my Educator and one of our Directors with several decades more clinical and debriefing expertise.

    On this note as well I have a bit of a curious question around debriefing for those who have minimal clinical knowledge foundation. I am always flabbergasted by the incredible expert debriefers that I have heard on a number of podcasts who have no healthcare background. I always thought how much more difficulty this must be for them without the healthcare background. However I am curious to know if perhaps there is some benefit to not having any “clinical skin in the game”? Perhaps removing some of the cognitive load of protecting your professional identity as a clinician can be beneficial when debriefing.

    As a side note there are still several trocars floating around the office from the birthday celebration and I am growing increasingly nervous after the last few episodes with the Murder Crew.

    • Jenn Dale-Tam

      Hi Zachary,

      When it comes to debriefers and medical knowledge, it’s about the objectives of the simulation: CRM, medical knowledge or both. Use self reflection on our parts as to what our expertise is in light of the objectives. If one does not have the expertise on a topic covered by the objectives, have a content expert present or a co-debriefer with the required knowledge to decrease one’s cogntive load as suggested in the article.

    • Ben Symon

      Hey Zach,
      Your comments are always funny, intelligent and clinically relevant, thanks so much for the effort you put in to them.
      With regard to your question about debriefing when you’re not a subject matter expert, I would agree there are a lot of expert debriefers who are very comfortable facilitating a conversation about a skill they’re not entirely familiar with. I think the paper that changed this for me was ‘Learner Centered Debriefing for Health Care Simulation Education’, as well as Kate Dennings article on ‘Listening through the learning conversation: a thought provoking intervention’ at https://www.mededpublish.org/manuscripts/1922

      Essentially for me, the more I try and practice humility and remember the importance of the learner’s words over my own, the more comfortable I am not being the expert in the subject at hand. For me the biggest cognitive load drop over the last year or so has been releasing myself from the expectation that I need to form the perfect question, and instead focusing on listening to what people are actually saying.

      Looking forward to working with you more mate.
      Ben

      • Zachary Buxton

        I really like the sentiment you’ve expressed here. No no not the sentiment that I’m funny and smart (although thanks!) But rather the idea that things got easier for you once you focused more on the listening and less interested he phrasing.

        Keen to give a read of the article you’ve linked as well!

  • Jenn Dale-Tam

    Hi Ben,

    If Nimali and Nitin can solve the murder of Snythe via a debrief, excellent! Simulation educators can moonlight or have a second career as detectives :).

    I am a devotee of Cognitive Load Theory (CLT). I find it straightforward to understand and easy to apply. It’s one of my “toolbox” theories for instructional design. I have not really reflected on my actions as a simulation educator using CLT specficially. Let’s give it a go.

    Employed as a staff development educator I have the joy of working with a core group of learners progressing from novice to expert or anywhere in between during the learning journeys of their careers. During simulation sessions with these individuals I initially struggled with the intrinsic load of psychological safety of the healthcare professionals as a novice debriefer while managing the extrinsic load of video technology. During the pre-briefs the tension would become palpable with the mention of secured video recording to use during the debrief. This increased my anxiety as I wanted the experience to be a good one for my colleagues and learners. During the debriefs, being a solo debriefer, the video technology never seemed to work right, many times I would have to ask the sim tech to set it up for me. This in of itself is disruptive to the debrief adding to my extraneous load while taking up my germane load. The schemas just would not form on how to use the videos efficiently and I was so focused on the needs of my learners’ psychological safety. Fast forward 12 months I decided to trial not using the video during the debriefs. It was like a weight had been lifted from my shoulders and the learners were more relaxed in the debrief. After a small literature search, the evidence appeared inconclusive for the use of video during debriefs so I decided not to use them anymore. The learners also stated they preferred not using the video during the debriefs.

    Table 1 in the Fraser et al article is a beautiful summary of the cognitive loads experienced by simulation educators along with mitigation strategies. One of the most powerful tools I was introduced to by my simulation mentor was the PEARLS debriefing framework. This decreased my intrinsic load while managing the extraneous load of facilitating a debrief which is now the schema in my brain for debriefing.

    In summary this is an articulate article that is an essential read for new debriefers and simulation faculty development educators. Having not known about CLT until a few years ago, it would have helped at the beginning of the journey to becoming a simulation educator.

    Thank you for discussing this.

    • Ben Symon

      Hi Jenn,
      Thanks so much for your time and the way that you tirelessly come every month to contribute with such thoughtful discussion, I’m very grateful.
      I agree video can be one of the biggest pieces of extraneous load in a debrief for me. The inevitable tech or sound issues can be distracting, I can never seem to get my marks right, and I’ve certainly noticed a trend in our workplace to stop using video altogether. I personally think if I get better at it it can be useful, and I certainly remember seeing my own performance useful as a learner. Although I did probably spend too long analysing how thin my hair was getting.

    • Zachary Buxton

      I had the opportunity to see someone use video in debriefing at one of our PEM Teams courses and I was quite surprised because so few people I know use it. Mainly, from what I have gathered it is not utilised for the reasons mentioned above.

      However the point was made that the debriefer actually felt that it gave him an opportunity to collect his thoughts as he allowed participants too review the actual action / event he wished to use the videotape to highlight. I am not sure what others thoughts are on that but it was a very interesting moment as I have always felt video was an added load and to have it reframed as potentially helpful to manage your cognitive load was unexpected but interesting!

  • Eve Purdy

    Ben, thanks for another riveting chapter in the saga.

    I quite liked this paper, probably because it merged two of my realities – being a novice debriefer and being a senior resident learning the craft of resuscitation. To me it was a nice reminder that managing cognitive load – in both of these settings – doesn’t just happen in the moment but it happens before, during, and after….as others have alluded to structure at all of these stages is probably helpful. In the resus room for me it looks like a good structured team briefing, ABCD’s loops for the case, then an after action review…..for my simulation that looks like a good pre-brief, some type of structure (PEARLS for me), and feedback (though admittedly this hasn’t been particularly structured)….

    My favourite tip was regarding content expertise. Increasingly I have found that it is often actually already in the room (though sometimes bringing it along might be necessary)…so you could turn to a co-debriefer or you might turn to a participant.

    Though cognitive load certainly is an issue for me, the bigger problems I have had in debriefing (and resuscitation) lately relate to emotional load affecting my cognitive load. And here I am not talking about a sad case but usually the emotional load that comes from a surprisingly poor interaction with a colleague or some serious countertransference related to a simulation participant. Managing the interplay of emotional and cognitive load is something I haven’t quite sorted out…….any tips would be most welcome!

    • Ben Symon

      Hey Eve, this is an interesting thorny problem you’ve described. Emotional vs Cognitive load. Do you mean containing your emotion during a debrief or do you mean there are conversations which are in and of themselves emotionally charged?

      • Eve

        Hey Ben,

        Mostly I mean the bandwidth it takes up to digest and respond in the way that I really would want to to relatively surprising behaviours or comments. These are rare(ish) scenarios but significantly affect what I have left for cognitive load in those moments…if that makes any sense?

        Eve

  • Sarah Janssens

    As I read this with a glass of wine in hand after a long day of the first version of our new programme, it touches on so many aspects of my day. The intrinsic load was high due to the unfamiliar scenarios (even though I wrote many of them!), implementation of RCDP scenarios and not being able to anticipate the usual participant performance. With the extrinsic load of “managing the day”, onboarding other faculty, and considering content revision, it’s not surprising to me that, on reflection, I didn’t once today think about how I could improve myself as an educator. And I’m totally overselling how hard I worked as had the amazing Sharon Clipperton as my co-lead!.
    The article focuses on reducing extrinsic and intrinsic load to increase ability to reflect “in action”, but I think these strategies are required to simply perform at a basic level when learning to debrief, or as we did today, implement a new curriculum. So it makes me think that we should all use these strategies – just to “survive” when we are new to debriefing, rolling out a new programme or experiencing other forms of high cog load (like emotion! – thanks Eve). Rather than necessarily giving us space to “go meta” during the debrief it can help us just “be okay”. And being in the habit of using these techniques will allow for the “reflection in action” to come in time, and that’s when our skill trajectory will skyrocket. Until that happens, as mentioned in the article we can use all those other strategies to improve – reflect after action with peer feedback and reviewing recordings of debriefing.

    Thanks for such a great article Ben – so relevant not only to novices but to all levels of expertise. I’m hoping the Mater team can report back later if our curry night isn’t before your close the commentary!

    • Ben Symon

      Wine and curry! Sounds delightful, and thanks for taking the time to read the article after a long day of teaching a new programme!

    • Zachary Buxton

      I think Sarah is almost certainly exaggerating any of the difficulties she mentions. I have seen her in action and she always seems to be On. Her. Game. Although it is absolutely true that she’s got a great crew to help deliver some really great educational content. The best of them are ruthless in their self reflection/improvement though.

      Sarah it secretly relieves a bit of my stress that even the experts I see in action on a daily basis struggle on occasion. It’s like “santa” comes on overhead and says “you have permission to feel stressed”.

  • Jennifer Dale-Tam

    Hi Ben,

    If Nimali and Nitin can solve the murder of Snythe via a debrief, excellent! Simulation educators can moonlight or have a second career as detectives, though, in essence as debriefers that’s what we are ;).

    I am a devotee of Cognitive Load Theory (CLT). I find it straightforward to understand and easy to apply. It’s one of my “toolbox” theories for instructional design. I have not really reflected on my actions as a simulation educator using CLT specifically. Let’s give it a go.

    Employed as a staff development educator I have the joy of working with a core group of learners progressing from novice to expert or anywhere in between during the learning journeys of their careers. During simulation sessions with these individuals I initially struggled with the intrinsic load of psychological safety of the healthcare professionals as a novice debriefer while managing the extrinsic load of video technology. During the pre-briefs the tension would become palpable with the mention of secured video recording to use during the debrief. This increased my anxiety as I wanted the experience to be a good one for my colleagues and learners. During the debriefs, being a solo debriefer, the video technology never seemed to work right, many times I would have to ask the sim tech to set it up for me. This in of itself is disruptive to the debrief adding to my extraneous load while taking up my germane load. The schemas just would not form on how to use the videos efficiently and I was so focused on the needs of my learners’ psychological safety. Fast forward 12 months I decided to trial not using the video during the debriefs. It was like a weight had been lifted from my shoulders and the learners were more relaxed in the debrief. After a short literature search, the evidence appeared inconclusive for the use of video during debriefs so I decided not to use them anymore. The learners also stated they preferred not using the video during the debriefs.

    Table 1 in the Fraser et al article is a beautiful summary of the cognitive loads experienced by simulation educators along with mitigation strategies. One of the most powerful tools I was introduced to by my simulation mentor was the PEARLS debriefing framework. This decreased my intrinsic load while managing the extraneous load of facilitating a debrief which is now the schema in my brain for debriefing.

    In summary this is an articulate article that is an essential read for new debriefers and simulation faculty development educators. Having not known about CLT until a few years ago, it would have helped at the beginning my journey to becoming a simulation educator. Many of the strategies suggested in the article I employ now, but have had the privilege to be mentored and be part of a simulation fellowship where much of this was learned.

    Thank you for discussing this :).

  • Victoria Brazil

    Hey Ben
    What a marvellous discussion you have prompted.
    I see the effects of cognitive load on simulation debriefers every day – both in myself and in those i help develop these skills.
    As others have described that load can be considerable
    – technical delivery of sim
    – maintaining rapport with participants
    – observing and analysing performance gaps
    – triaging what topics to debrief about
    – listening to participants
    – emotional responses to participants (cannot always maintain that basic assumption. Eve 🙂
    – formulating questions

    no wonder when we actually uncover a frame – we don’t know what to do with it !!

    Personally i notice that fatigue reduces my overall cognitive capacity – and i notice it when debriefing on that day every 2 weeks when i do a lunchtime sim after a Sunday night on call – so indicates to my how close i am to that capacity limit a lot of the time when debrieifing.
    I see that limit often exceeded in novice debriefers.. ( they tell me worse when i am watching them 🙂

    Of course structure helps, and being involved in sims where i am truly interested in the participants issues and their actions helps enormously..
    That and shifting from being a clinical content expert to slightly more of a team science content expert has also helped … my repertoire of ways to talk about team issues is much broader than it used to be … ( and i hope continues to get better yet..)
    Centre for Med Sim describe a ‘debriefer self-rescue’ repertoire for many situations, and i think this is very pertinent here.

    Thanks again for insights

    vb

  • Janine Kane

    Hi Ben,
    I love the ongoing saga of Nimala and Nitin. It pushes me to read the article associated with the current story line 😃. As far as debriefing goes, i have to debrief on my own most of the time but am very fortunate to have a co SIM partner in crime who co debriefs with me on the last day of our SIM program. Fortunately my program only changes slightly from time to time based on feedback from students etc. the cognitive load for me therefore, is not so high now. repetition builds skill and as I have repeated the SIMS many many times over the last few years this has given me confidence and familiarity when completing the debriefs. I don’t have a preference re debriefing however when the scenario’s are back to back over 3 1/2 hrs, debriefing on my own means we can flip pretty quickly from scenario to scenario. I also feel that the pre brief and clear learner goals help me when debriefing . I can refer back to those goals if we get bogged down in the de brief by that one student that wants each debrief to focus solely on them each time! 😬 really looking forward to the next episode 😃