Journal Club Summary August 2016 – Debriefer Knows Best

Introduction : 

Simulcast Journal Club is a monthly series heavily inspired by the ALiEM MEdIC Series.  It 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.  We moderate and summarise the discussion at the end of the month, including exploring the opinions of experts from the field.

The article below is our summary for the case for August 2016 : Debriefer Knows Best.  To read the original case and journal club discussion, please click here.  You may also prefer to download the attached pdf to keep as a resource.

Title : “Debriefer Knows Best”

The Article : 

“Learner-Centered Debriefing for Health Care Simulation Education : Lessons for Faculty Development”

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

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 some benefits to an Instructor Centred approach in some circumstances.

Questions : 

1. Having read the article, where do you think you sit on the continuum between Learner and Instructor Centered Debriefing?  Has reading this article changed your stance?
2. Do you find it challenging to relinquish control of the learning objectives to your learners?
3. Conversely, it may be difficult for some Learners to share responsibility for the debriefing outcomes!
4. What strategies have you found useful to assist you in collaborating more with your learners in the Simulation setting?
5. 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?

Article Summary : 

In the article “Learner-Centered Debriefing for Health Care Simulation Education : Lessons for Faculty Development”, Cheng et al state that they will :

• Compare and contrast learner vs instructor centered approaches to teaching
• Provide a rationale and conceptual framework for a more learner centered approach
• Describe key variables to consider when managing the balance between learner and instructor centered debriefing.
• Describe practical learner centered strategies for various debriefing phases.

In contrasting learner and instructor centered debriefing, the authors reference Maryellen Weimer’s text “Learner Centered Teaching” in describing a spectrum of teaching strategies that vary between two extremes as exemplified by their diagram:

Using the analogy of ‘The Guide on the Side’ vs ‘The Sage on the Stage’, the authors argue that Learner Centered Debriefing :

• Shifts the balance of power and responsibility to the students, leading to them becoming “typically more motivated to learn” and “active meaning makers”.
• Increases “student engagement with content, student learning and long-term retention of knowledge”

In defining Instructor-Centered Teaching, they state that it :

• “Emphasises teaching activities and deemphasises learning processes.”
• Is “based on the premise that transmitting information is most efficient and effective”
• Places responsibility for learning primarily on instructors
• May unintentionally “promote dependent, instructor-centered learners”

With the assistance of multiple tables the authors then provide a Conceptual Framework for Learner- Versus Instructor-Centered Debriefing, Key Variables to Consider When Managing the Balance Between Learner and Instructor-Centered Debriefing and finally a series of pointers on how to approach a more learner centered debrief with specific advice regarding each phase of debriefing.

Expert Opinion : Dr Mary Fey, Associate Director of the Center for Medical Simulation, Boston, Massachusetts.

Mary Fey has been working in the field of clinical simulation since 2007 and has been responsible for developing clinical simulation programs and integrating simulation into nursing curricula.  She is Assistant Professor at the University of Maryland, School of Nursing and the Associate Director of the Center for Medical Simulation in Boston, Massachusetts.  Dr Fey is a co-author of ‘the Standard of Best Practice for Simulation : Standard VI, The Debriefing Process’.  She serves on the research committee of the International Nursing Association for Clinical Simulation in Nursing, as well as on the Certification Committee of the Society for Simulation in Healthcare.  She holds a PhD and a Post-Master’s Certificate in Teaching from the University of Maryland.

This Simulcast Journal Club has helped us all think about the teacher-learner relationship.   Through all of the discussion and the paper, the meta-message is:  “learner centered” is deeper than the actions we take; it’s the belief system of the teacher.  Being learner centered begins with holding the basic assumption that the learners are intelligent, capable, doing their best and want to improve. Holding this belief system compels us to partner with the leaner to co-create meaning.   Not an easy task!  Many of the complexities of learner-centered debriefing have been well stated in others’ posts.

As pointed out by Vic and Cliff, context is everything.  Decisions about how to facilitate a debriefing are influenced by multiple factors, including:  available resources (e.g. time), faculty expertise, level of learners, etc.  One size does not fit all.  Ben (and others) have made the point that there are times when techniques on the “instructor centered” end of the continuum may be best for learners.  E.g. Cath can satisfy one of Dale’s important learning needs by giving him the information about initiating a trauma response.  This allows her to concentrate on learning needs related to clinical decision making and interprofessional communication.

Shannon reminds us that there are multiple ways to extend the learning beyond the debriefing room. Learners can continue to be supported when they are no longer with the instructor.   This may be done through the provision of resources tailored to their learning needs, or by extending the conversation using techniques like wikis, discussion boards, and post simulation review of video.

All of these points illustrate the foundation of learner-centeredness.  It is not so much about the instructor actions, as it is about how the instructor views the teacher-learner relationship.  As stated by the authors of the paper, it is a focus on learning rather than teaching.  It is a core belief that the best way to chart the course to improved practice is to partner with the learner.

The paradox is this:  ultimate teacher control over learning outcomes is gained by sharing control with the learner(s).    Diagnosis and treatment of their learning needs is best accomplished in partnership with them by (1) finding out which learning objectives are most important to them, (2) exploring the cognitive frames driving their actions and (3) tailoring debriefing to move them along the trajectory to improved practice.

Holding the learner in high regard while holding them to high standards encourages what Carol Dweck calls a “growth mindset” – a belief that learners can achieve the ultimate outcome through sincere effort.  The converse is also true, as Ian points out so well:  There is no point saying that you are sharing control if the first time someone disagrees with you your body language shows annoyance.  Learner centered isn’t something you do – it’s something you are.

Summary of Simulcast Journal Club’s Discussion : 

Blog Contributors (in alphabetical order) :

• Nick Argall
• Vic Brazil
• Cliff Reid
• Shannon Scott-Vernaglia
• Jesse Spur
• Ian Summers
• Ben Symon
• Callum Thirkell
• Brent Thoma
• M C Yuen

Themes : 

While the discussions this month were varied, they could primarily be condensed into three separate themes :

• ‘All Things in Moderation’
• ‘Debriefing format should change depending on targeted learning outcomes’
• ‘Transition of responsibility for learning is a journey within itself’

‘All Things in Moderation’

• “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.” – Ian Summers
• While all blog contributors were in agreement about the significant merits of a LCT approach, many voiced concern about the potential risks of approaching either extreme of the ICT/LCT spectrum.
• It was argued that being fully Learner Centered may not lead to achievement of targeted learning objectives, particularly as learners and instructors are susceptible to being influenced by what learners like, and learners may need more clear guidance to “known what they don’t know” or uncover blindspots.
• The evidence base for the superiority of LCT was challenged in the context of minimal evidence of improved learning outcomes in medical curricula moving from an ICT focus to Problem Based Learning curricula.
• It was voiced that there is an inherent ‘hidden curriculum’ dichotomy in designing a simulation with key learning objectives and then asking learners to come up with their own.
• LCT focused debriefing is more difficult to achieve and may be inappropriate for the novice debriefer to venture so far down that path that they get significantly derailed to the detriment of the learner’s experience.
• Potential solutions for these identified problems included :
• Allowing for a learner centered debrief but following up with instructor centered educational resources may safeguard against failing to meet targeted learning objectives
• Moving fluidly between the ICT and LCT spectrum according to the acute temporal needs of the debrief.

‘Debriefing format should be different depending on targeted learning outcomes’

• In exploring the potential flaws of extreme approaches, a discussion around the type of simulation format most appropriate for different learning objectives emerged.
• Summarised as the difference between “simulation as a tool for training’ versus ‘simulation as a tool for exploration”, the suitability of an LCT focused, long form debrief for skill acquisition was challenged.  It was advocated that “Learners should not ‘make their own meaning’ if they are being instructed’. Rapid Cycle Debriefing was flagged as being more appropriate for this purpose for skills acquisition, given its suitability for a more ICT focused, skill improvement objective.

Transition of responsibility for learning is a journey within itself

• Being an active participant in debriefs is a skill that must also be learned, and as such more reserved learners will often evolve from being passive observers to being active participants if given the time and simulation experience.
• Debriefs may benefit in mirroring that journey in evolving the debrief from ICT to LCT as courses progress and this was echoed by multiple contributors sharing their personal experiences teaching on short courses versus taking a regular group of learners on a longer term journey through simulation, and noting a natural transition towards learners taking ownership of the debrief as time progresses.
• Cultural contrasts in debriefing where highlighted by MC Yuen, who highlighted that participants in Chinese culture may be unable to advocate for their own learning needs and will take more effort from the debriefer to encourage learners to express their opinions and concerns.

Acknowledgements : 

Simulcast would like to thank the creators of the AliEM MEDiC series for the inspiration for the journal club’s blog format and their ongoing support and contributions to the project.

Thankyou to Dr Mary K Fey @marykfey , Associate Director of the Center for Medical Simulation for her expert commentary this month.

References : 

• 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
• Weimer M. Learner Centered Teaching. 2nd ed. Hoboken, NJ: Wiley & Sons; 2013.
• Hartling L, Spooner C, Tjosvold L, Oswald A. Problem-based learning in pre-clinical medical education: 22 years of outcome research. Med Teach. 2010;32:28–35. doi: 10.3109/01421590903200789.