Deliberate practice, feedback and debriefing
Clinicians can use simulated facilities to rehearse both challenging and routine procedures to reduce error (Yule et al., 2006). The philosophy is based on deliberate practice with appropriate feedback and reflection (both during and after the training event). Because simulation focuses primarily on skills acquisition (technical or non-technical), it is essential that learning activities are planned with clear learning outcomes and that a debriefing or follow-up stage is planned.
Deliberate practice refers to time spent on a specific activity designed to improve performance in a particular aspect of practice and is more effective than simple unstructured practice. There is a consistent association between the amount and the quality of deliberate practice and performance in domains as varied as chess, music and sport (Ericsson and Charness, 1994). Deliberate practice means that there is effort involved as well as some form of feedback, whether through self-assessment, from the simulator or observation by another person.
Short-term training courses are not the same as deliberate practice and do not have the same beneficial effects on long-term performance. Research on the use of laparoscopic equipment showed that structured practice with feedback improves subsequent performance in the same real-life situation (Reznick and MacRae, 2006). Deliberate practice using simulation is particularly useful for new skills, rare events or emergencies.
A lack of opportunity for practice is associated with a poor educational outcome. This is often attributed to insufficient access to the simulator, as training sessions are usually time-dependent, and the simulator is often a hotly-contested resource. In addition, each learner is different, and some learners inevitably need longer or more frequent sessions with the simulator to achieve the same educational results as their co-learners.
The absence of learner feedback is the greatest single factor for ineffective simulation training. A lack of feedback may lead to:
- Learning the wrong learning objective
- Not realising what the desired behaviours should be by not focusing on them
- Not transferring skills to clinical practice
- Spending increasing time on only one aspect of training
In this context, ‘feedback’ refers to the specific information provided to the learner about their performance against a defined standard or competency to help improve future performance. For example: You put exactly the right pressure on the chest when you were doing the compressions, however, the timing was not consistent and you need to practise again to get the right rhythm going.
See the How to Give Feedback module for more information on feedback.
The structured debrief
One of the key elements of the simulation experience is the debrief which is also widely used after critical incidents and in experiential learning. Debriefing enables the transformation of the simulation experience into learning (which hopefully can then be applied in practice) through reflection, feedback and discussion. The debrief provides an opportunity for a facilitated reflection through conversation to explore issues, and help the learner identify gaps or the need for more learning in their knowledge, skills or professional behaviours. Whereas feedback should not explore motives or rationale for actions (or omissions), debriefing does. It can therefore be very challenging to the learner as it is more critical and needs to be carefully facilitated within a safe learning environment.
Eppich, O’Connor and Adler (2013) suggest the structured debrief comprises the following components:
- Preparing the physical space – debriefer and participants usually sit in a circle
- Setting the stage and clarifying expectations
- Allow for initial emotional reactions (e.g. venting, defusing) to help participants come out of role – by asking an open question such as how do you think that went?
- Describe main events and primary issues to be explored so everyone is on the same page
- Discuss participants’ performance: what was done well, what could have been improved?
- Application of learning to future practice
- Summary of learning points
One model used in debriefing is ‘Debriefing with Good Judgement’, developed by educators at the University of Cambridge, MA, which uses the principles of advocacy-inquiry. In this model, the facilitator gives feedback on performance and also shares their point of view or judgement and inquires about the learners’ perspective (Eppich, O’Connor and Adler, 2013). This gives the opportunity for a professional conversation to occur, which goes much deeper than simple feedback and promotes the learners’ reflection and insight by surfacing the learners’ reasons for their actions.
For example: I noticed that you kept looking at your colleague when you were doing the chest compressions and not at the monitor, did you notice this yourself? And why do you think you did this? Such an observation might reveal that the learner was lacking in confidence in the technique, was seeking approval from the colleague or was expecting the colleague to count compressions for them. Whatever the reason for the actions, this opens up opportunity for a conversation that helps the learner perform better next time.
A very useful aspect of higher fidelity simulation is the ability to play back videos of the scenario that has been played out to an individual or team. With the widespread use of wireless and mobile technologies, this is an increasingly flexible tool which can be carried out in situ or remotely. Unlike verbal feedback from an observer, being able to play back a video provides tangible, detailed and specific evidence of what the learner did or did not do or say. In addition insight into how they behave under stress (getting angry, withdrawal, making mistakes) can be a valuable and powerful learning tool. It is important that the teacher focuses the participants’ attention on what they want them to observe specifically: purposeful observation.