Keywords

1 Introduction

To be a facilitator in simulation requires specific skills and knowledge in simulation pedagogy [1]. Being a facilitator when using high-fidelity simulation as a learning approach might appear to be a challenging, complex, and exhausting role. A great deal of preparations must be made concerning the practical prepping of mannequins, available equipment, surroundings, technology, adequate advance information to the participants, and cooperation with the staff involved. Moreover, insight into the target group’s starting point for learning is required, as well as awareness of the timeframe and learning outcomes. This also includes welcoming the group in a way that facilitates a safe and good learning climate and briefing the participants about equipment and technology. During the scenario, facilitating learning for both the group of actors and the group of responders must be kept in mind. In the debriefing, the facilitator must help the actors control and handle their feelings. Furthermore, the facilitator must act as a group leader, and is not only expected to be an expert in the current field but also to be learner-centered focused. All the participants must be engaged in active reflection and feedback. The learning outcome must be focused, but the facilitator also needs to improvise and prioritize depending on what appears as interesting and challenging for the participants to discuss. Realistic feedback must be given in a way that encourages the learners to listen, understand, and improve and progress in their learning. The facilitator is dependent on the current group size and dynamics—inspiring and stimulating when the dynamic appears as active, supportive, dialogical, and engaged, but exhausting and depressing when it is silent, monological, closed, and passive. Clearly, the facilitator needs tools to handle the simulation activity.

In this chapter, we want to present a structure for feedback which can help the facilitator to achieve their main objective of enabling the participants to achieve learning. But first a short summary of what is known about simulation, debriefing, and feedback is presented.

1.1 Simulation Activity as a Learning Approach

Simulation activity is a resource-intensive learning approach due to the equipment required, the learning surroundings, and people involved in operating and facilitating. It offers the potential for learning beyond the learning outcome such as training in feedback literacy and professional argumentation, situational awareness, and teamwork training. These are all considered to be important factors in building a patient safety culture. A patient safety culture requires everyone to have the courage to raise their voice and involves an openness to failures and success, mutual support, receiving and giving feedback, and a shared responsibility. The students need training during their education to participate in such learning environments with the aim of developing such knowledge, skills, and attitudes.

Learner-centered and lifelong learning are emphasized in higher education and require the learner to be active in learning and not to be dependent on teachers or facilitators. It requires learners to be able to evaluate their own performance, to identify their lack of skills or knowledge, and to take responsibility for progress in their learning. The strength of simulation activity is that it facilitates experimenting, failure, and detection of deficiencies, all learning conditions which are not possible in the clinic. However, if these additional effects are to be exploited, this must be reflected in how the simulation is carried out and how the debriefing is structured. Simulation activity offers the potential to supply what is underscored in higher education today: active learning, interprofessional learning, collaborative learning, and learner-centered learning [2,3,4,5]. Simulation is widely applied and frequently used in healthcare education and is often also used to maintain or enhance competency in healthcare units. Simulation can be used to help transfer theory into practice, improve logistical flow, and facilitate training in technical and non-technical skills [6]. In a simulation scenario, the participants can experience challenges in both handling a situation, communication, relational conditions, and personal factors. Thoughts emerge from what we see, hear, or touch and must be further developed into learning through reflective thinking [7]. This is known in the simulation activity as the debriefing phase.

The debriefing is considered crucial to achieve learning. The purpose of the debriefing is that the participants reexamine what took place in the scenario. This is a reflective learning process to help promote the development of clinical reasoning and judgment skills in an active learning environment. Debriefing offers the possibility to give and receive feedback, to resolve feelings, as well as the opportunity to learn from either successes or failures [1].

Let us take a closer look at the important factors for achieving learning from feedback.

1.2 Feedback as Part of Debriefing

Feedback is considered important in learning in general and an important part of the debriefing. Teachers and fellow students are important givers of feedback, as are colleagues and managers in working life. However, even if we all understand and appreciate feedback, it is regarded as a complex and multilayered concept with no common and agreed understanding of how to offer and provide it to achieve learning [8]. Lefroy et al. [9] offer a definition of feedback supporting self-regulating learning as follows:

Helpful feedback is a supportive conversation that clarifies the trainee’s awareness of their developing competencies, enhances their self-efficacy for making progress, challenges them to set objectives for improvement, and facilitates their development of strategies to enable that improvement to occur.

For feedback to contribute to learning, the students need to handle their emotional and relational reactions, and they need to have the chance to express themselves. They must appreciate the feedback and understand how it can be used in further learning and individual growth. This shows that the prerequisite for feedback to have a learning effect is that it is carried out as a dialogue [8].

Transferring this knowledge into a simulation setting is highly relevant. Even though it is emphasized that simulation is for learning, students report simulation to be stressful in terms of being put in the spotlight and assessed, while in their performance they are exposed in relation to both body and mind [10]. In particular, those performing in the scenario report that they feel in a vulnerable position that is characterized by a high risk of disgracing themselves and ending up in a stressful and intrusive situation [11, 12]. The feeling of having to defend and protect themselves might arise, which reduces their ability to make use of the feedback they receive [9, 13].

Studies reveal disappointing results showing that debriefing seems to be more based on the facilitators’ frames and dominance than the participants’ frames [5]. The facilitator tends to assume a role of prominence as in teaching in general [14], which does not accord with recommendations for stimulating students as self-regulated learners [9]. The facilitator’s feedback style and communicative abilities in facilitating are crucial and have a great impact on the learning climate [15, 16]. It is emphasized that the facilitators would benefit from practicing techniques for stimulating involvement and reflective practice in the participants [5, 15].

There is no clear evidence of when or how debriefing should be implemented to achieve learning and change [17, 18], but it seems that structuring the debriefing is of importance. Several frameworks are available to help structure debriefing in a purposeful manner [1]. However, the development of appropriate frameworks and ways of structuring debriefing adapted to the participants’ needs and the learning outcomes represents an ongoing process. There is also a need for further in-depth research into how dialogic feedback can enhance student learning [8].

1.3 Critical Response Process as a Structure for Debriefing

In the following, we present a structure for feedback called critical response process (CRP), evolved by Liz Lerman [13]. CRP underscores the value of dialogue, inquiry, and peer feedback, and it offers the actors the opportunity to exercise a degree of control in the criticism directed at their work based on the perception that “When defensiveness starts, learning stops” [13]. CRP originally evolved as an approach to group critiques on artistic work in progress. However, Lerman claims that its flexibility makes it suitable for different types of learning situations that involve feedback. The roles involved are artist(s) (called the actors in medical simulation), respondent(s) (one, few, or many), and a facilitator. These are parallel roles used in medical simulation, though respondents are often called observers. Inspired by Lerman’s work, we used this structure in debriefing as part of simulation activity, and in the following, we describe how we transferred and used CRP in medical simulation.

CRP includes a four-step method [13] summarized in Table 1.

Table 1 Critical response process
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1.3.1 Phase 1 Statements of Meaning

The respondents are requested to prepare one or two positive statements and formulate open questions about the actors’ performance. When the debriefing starts, each respondent gives the actors one response at a time on something they found to be good practice, impressive, engaging, thought-provoking, and interesting. Only positive feedback should be given at this stage with no addition of “… but….” Several rounds may be necessary to obtain all the positive responses. The rationale for this is that everyone must make their voice heard and give positive feedback at this first stage, which will probably lower the threshold for taking the floor in the later stages. The respondents address their feedback directly to the actors. Thus, the responsibility for providing feedback is established as a common concern and contributes to a standard of shared responsibility. The respondents describe what they found engaging and what was impressive and good practice, resulting in less focus on the facilitator’s feedback. Such reinforcement of what was done well promotes a climate of trust and learning. Consequently, this phase confirms good practice and what can be learned from it. Being the one to perform the scenario can be a stressful experience, and when entering the debriefing, studies have shown that the actors feel cognitive and emotional overloaded and vulnerable [11, 12]. At this stage of the feedback, the actors get a well-deserved break after the stress of performing the scenario, and they are filled in with positive descriptions of their work. This gives them time to gather their thoughts and take control, enabling them to receive further feedback with reduced emotional distress and self-criticism. These are all factors which are underscored in providing useful feedback and thereby achieving learning [9, 13].

1.3.2 Phase 2 Actors as Questioner

In this phase, the actors raise all their questions about their own performance, and the respondents answer honestly, discuss, and reflect. This makes the feedback learner-centered in that it is controlled and based on the actors’ need for learning and understanding of the situation. The respondents propose answers leading to reflection and dialogical feedback.

The actors keep control by raising questions about their own performance. This phase reduces the need for the respondents and facilitator to give negative feedback on mistakes, wrong priorities, or a lack of skills and knowledge. It is easy to give honest responses because the actors ask for it. The positive climate in this phase seems to enable the actors to dare to put their practice under debate, being open for responses which lead to further dialogues between the students about alternative solutions and priorities implemented in the scenario. By themselves being the ones who put their actions and priorities under debate, they keep control and are open to feedback on what they themselves perceive as relevant issues from the scenario. This provides the facilitator and the respondents with insight into the actors’ needs for reflection and learning.

1.3.3 Phase 3 Neutral Questions

Each respondent asks the actors neutral, open-ended questions about their performance. Being an actor in the scenario means to be exposed. Defensiveness and self-protection may occur, leading to poor learning conditions and feedback not being given in timely manner to support learning [9, 13]. Neutral and open questioning gives the actors the opportunity to discover, explain, reflect on, and assess their own practice. Emphasizing open and neutral questions does not trigger the need for defense but facilitates for feedback as a supportive conversation. If necessary, the facilitator must help the respondents reformulate questions so that they are open and neutral, leading to a question-based dialogue. This phase can help increase participants’ awareness and training in giving and receiving feedback in general and is an important additional effect of simulation activity. It is important that the facilitator creates a climate that involves an openness to failure and success, where all participants are aware of the importance of mutual support for good cooperation. Simulation activities can offer a learning environment aimed at enabling students to develop abilities which are considered important in building a patient safety culture.

To avoid taking focus away from valuable discussions and conversations between the actors and the respondents, it is an advantage if the facilitator waits until the students have given feedback and asked their questions. However, the facilitator must ensure the quality of comments from the respondents and the actors to ensure professional soundness.

1.3.4 Phase 4 Option Time

Each respondent offers the actors suggestions or advice for change, opinions, and strategies for further learning. The advice/suggestions must be honest, concrete, and understandable for the recipient. The advice and suggestions deal with progress in learning and strategies for further learning. This is done in a kind of ritual by the respondent telling the actors what the advice/suggestion is about and then asking if they want to receive it. An example could be “I have some thoughts about how you communicated with the patient. Would you like to hear these?” The actor(s) has the option to answer yes or no. This ritual seems to be perceived as rather weird by the students; often smiles and humor appear in this phase. The ritual of telling the content of the advice and asking if they want to receive it is based on the goal of giving explicit control to the recipient of feedback. There is no point in giving feedback if the recipient is not motivated or responsive.

The option/advice is often positively charged (“Keep on like you showed us today; it was impressive”) but also includes areas for improvement and how to proceed in learning. The facilitator possesses many roles in CRP: to relieve the performers if they are highly emotionally affected and to prevent the focus on the negative aspects that accompany free discussion. However, sometimes, the facilitator should act as “the bad guy” if the respondents are too polite or reluctant to give honest advice about lack of skills, knowledge, and attitudes for good practice. In a patient safety perspective, simulation activity might be a dangerous way of learning if the actors leave the setting with a false self-esteem and belief that this went well without recognizing the need for more training and learning to improving practice.

1.4 Exploring Two Structures for Debriefing and How They Influence the Facilitator Role

There is a lack of knowledge about how to structure debriefing to achieve the purpose of the simulation activity, which is active and learner-centered learning, and less dominated by the facilitator’s frames and control. Inspired by this, we decided to conduct a study using a quasi-experimental multi-method, comparative design. A full presentation of the study has been published [19].

Two structures for debriefing were included. The first was a well-known structure in medical simulation, the Steinwachs structure [20], originally developed to facilitate the debriefing phase in gaming education. It includes the recommended minimum phases of reaction, analysis, and summary [1]. In the first phase, the description phase, the facilitator challenges the actors to describe what occurred in the scenario, with the intention of airing their experiences and impressions and exchanging their perceptions with the respondents. In the second phase, called the analogy/analysis phase, the actors explore, analyze, and reflect on alternative solutions, relevance, success, and failure. In the third phase, called the application phase, the actors and respondents express what is particularly relevant and the consequences for further learning. The facilitator gives their attention to the learning/reflection process and strives to get everyone to participate in the debriefing and contribute support in the discussion. This basic structure can be recognized in several of the available structures used in debriefing in medical simulation.

The second structure included was the critical response process (CRP). The rationale for the choice of including this structure was that it deviates from the recommended minimum phases of reaction, analysis, and summary [1]. To the best of our knowledge, CRP has not been previously used as a structure for debriefing in medical simulation.

The data was collected from the end of April to the end of May 2017, and all debriefing sessions were videotaped by using a Swivl iPad. Following the debriefing, the students completed the Norwegian translated version of the Debriefing Experience Scale [21], and the facilitator wrote notes after each debriefing.

The sample consisted of undergraduates in bachelor of science in nursing in the second year of their 3-year program. They were conducting their 9-week clinical practice, either in medical or surgical wards. Out of 168 students, 155 participated in the study. They were divided into 15 groups, with a group size between 6 and 13 students. To be well prepared, the students received the scenarios some days before the simulation activity. Two students performed each scenario, and the others were respondents. Immediately before starting the simulation activity, the facilitator randomly picked a note describing which structure (Steinwachs or CRP) to use in the current debriefing. The same facilitator facilitated all the simulation activity sessions.

Based on the results from the time registration of the facilitator’s verbally prominent role and the students’ response to the Debriefing Experience Scale, there was no difference between using Steinwachs and CRP structure. However, in analyzing the videos and facilitators’ notes, the facilitator’s role concerning control, dominance, and responsibility clearly differed, which in turn affected the actors’ and the respondents’ roles. Even though there was nearly no difference in how much of the time the facilitator talked, there was a clear difference in what they spent their time on.

When using Steinwachs structure, the facilitator appeared to have the dominant role. He was in control, being responsible for feedback, raising questions, verifying, and asking follow-up questions—a conversation that mainly included the actors in the scenario and the facilitator. The actors addressed questions and responses to him, and the whole group focused on the facilitator as illustrated in Fig. 1.

Fig. 1
An illustration depicts the prominant roles in Steinwach's structure based on user feedback. The roles for actors are describing and answering while for facillitator, leading, asking questions, correcting, confirming and follow up.

Prominent roles using Steinwachs’ structure based on observation

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When using CRP, the facilitator’s role seemed to be as a leader of the group discussion, introducing new phases and helping reformulate questions if necessary. Each phase of the CRP structure forced a transmission of the responsibility and control from the facilitator to the respondents and the actors, as illustrated in Fig. 2.

Fig. 2
An illustration depicts the prominant roles in C R P structure based on the transmission of responsibility. The roles for actors are receiving feedback, asking questions and answering while for facillitator, group leader and responder.

Prominent roles using the CRP structure based on observation

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After using CRP, the facilitator noted their concern about losing control, a fear of not achieving the learning outcomes. Since the students were the ones giving feedback and asking questions, CRP seemed to safeguard a more comprehensive focus on the “nursing performance.” In contrast, in the Steinwachs structure, the facilitator’s feedback and questions seemed to break up the performance into details connected to the learning outcomes (ABCDE, communication, leadership). However, when analyzing the videos and the students’ responses to the questionnaire, learning outcomes appeared to be the dominant focus in both structures.

The two structures differ from each other from the start. The first phase in Steinwachs structure involves the actors as actively being challenged to describe what they observed and which actions they took. However, the facilitator did not report to miss the description phase when using CRP. Often in the description phase, it was necessary to interrupt because the actors started to analyze immediately, sometimes leading to frustration and confusion because the actors could not see the difference between describing and analyzing.

In the beginning of the study, Steinwachs structure gave the facilitator the best feeling of control over the debriefing to ensure focus on the learning outcomes. As the study progressed, CRP became the preferred structure for the facilitator. Although the fear of losing control was still present, the facilitator felt it was a relief to transfer and share the responsibility for the debriefing with the respondents, and not have to make a big effort to stimulate student activity. Perhaps the facilitator’s eagerness to keep control can hamper the students’ learning. CRP gives the facilitator a better opportunity to focus on group dynamics, formulation of questions, and learning outcomes.

2 Conclusion

In this chapter, we have presented critical response process as a structure for debriefing based on a study focusing on how two different structures affected the facilitator role. In our experience, CRP offers a structure for debriefing that well facilitates active, learner-centered, and collaborative learning. It emphasizes feedback as maintenance of dialogue, mutual support, and open and non-judgmental responses, all of which safeguard essential factors for feedback leading to learning. CRP offers a great opportunity to put the ability to give and receive feedback on the agenda. This is an important part of learning and essential in building a patient safety culture. The responsibility for conducting a debriefing is transferred to the learners as intended, and the facilitator gets the chance to truly be a facilitator. An alternative when using CRP with many respondents is to divide them into groups so they can discuss and give their positive comments, questions, and action options as a group to the actors in the debriefing. This pre-debriefing will lead to a lot of extra learning, with discussions on how to formulate questions to achieve constructive conversations.

Debriefing is an important part of simulation activity to achieve learning. Feedback is a part of debriefing and is described as a complex and multilayered concept. There is no common and agreed understanding of how to offer and give feedback to achieve learning, besides the importance of stimulating self-reflection. However, essential factors must be safeguarded to make feedback useful for learning. Simulation activity offers the participants a learning environment for training and developing feedback literacy. CRP seems to be a structure for debriefing that facilitates such training. How debriefing is structured and how the facilitator fosters such training are of great importance. Simulation is a resource-intensive learning approach, and in addition to achieving the given learning outcomes, emphasizing and utilizing such additional effects can make simulation activity an effective learning approach.