To be Honest …

I am working on a concept analysis of prebriefing. It’s a thing you do as part of your research anyhow, and it’s for a class (of course). But I am getting a lot out of it. Much like my  last post that talked about my why for this topic, I am now seeing my what– as in what do I want to do in this topic?

I have said before, I want to lay the ground work for a framework for prebriefing, much like there is for debriefing (there are many, in fact). As I review this literature, I am beginning to form an idea, and I need to write it down here. Bear in mind, I am brainstorming, so I am not citing all the great minds who have come before me in this field. But I will say there are a few names who pop up regularly in prebriefing- and as a baby novice researcher, I’d like to connect with at some  point:

Donna S. McDermott, PhD, RN, CHSE

Karin Page-Cutrara, PhD RN

Jill Chamberlain, PhD RN

Anyhow back to me.

I think that while I might only be aiming to gather survey data about prebriefing (and participant preparation) practices in prelicensure nursing programs, I have a larger goal if I continue in research and in this field. I see that prebriefing is finally getting research attention. And while the INACSL Standards of Best Practice: SimulationSM continue to separate out the concepts of prebriefing and participant preparation, we need to move to a more integrated framework for the activities that take place before the simulation.

Once I collect data about what educators are actually doing in their simulations, I feel I can make the following proposal:

Best Practice is not just what everyone is doing,  but sometimes what everyone is doing (especially in a field that is young, yet well established like simulation) might be a good starting point. I think we need to develop a framework that is supported by the experts, learning theories and the reality of practice to structure the elements of prebriefing. It must be more than an orientation or a speech about “safe space” It should be in phases. Each phase addresses a learning domain.

The preparatory phase (cognitive domain) where learners prepare by learning about the the content they will encounter in the simulation. They may review pathophysiology or medications. Or develop concept maps or care plans for their simulated patients. They will be accountable for this prep work. This phase allows the learner to develop a foundation on which to build their learning in the scenario.

The orientation phase (psychomotor) which allows the learners to hands on experiment with equipment, or examine the space the simulation will occur and become familiar with it. In this phase, they may even review skills that may be required in the simulation whether it is auscultation of the mannikin or insertion of a foley catheter. This phase allows the learner to gain some comfort and eliminate distractions so they can focus on their higher level actions and decisions in the scenario.

The prebriefing phase (affective) where the facilitators reviews the expectations,  elements of psychological safety, fiction contract, the process of debriefing and other aspects that will provide a safe and respectful learning environment for the participants.  This phase is intended to help alleviate the learner’s anxiety going into the simulation and give them a sense of self-efficacy.


Yeah so, that’s my idea.


Why Pre-Briefing???

Pre-briefing is a crucial element of simulation which allows students to have a learning experience that is both valuable and retained.

I have been reflecting on my research interest. I had to do a discussion board posting in one of my classes that addresses my research phenomenon and concept. In that I reflected on what led to my interest in this topic. I realized is was borne out of my experiences with simulation. Observing the impact of preparation for simulation on students, and their response to the experience. Also, I am driven by my passion as an educator to shake up the traditional culture of nursing education which I have observed to be punitive and rarely student centered.  Simulation  is an opportunity for nursing education to move from behaviorist approaches to more constructivist and humanist approaches.

Pre-briefing is a crucial element of simulation which allows students to have a learning experience that is both valuable and retained. Much like care planning allows a nursing student the opportunity to prepare and plan out the interventions and care they will provide to their patients based on the patient’s own needs, a structured and comprehensive pre-briefing gives the nursing student the tools to interact in a simulation while focusing on the clinical decision making and clinical judgment aspects of nursing practice.  With good preparation, the use of clinical judgement and clinical decision making become the focus of the learning objectives of the scenario.

Simulation is the one safe environment where nursing students can bring together and act on the three domains of learning: cognitive, psychomotor and affective. For nursing students, traditionally cognitive learning occurs in their theory classes, memorizing lab values, symptoms of disease and medication side effects, assigning nursing interventions to disease and pathophysiology. Psychomotor learning happens in a skills lab setting, practicing invasive skills repeatedly on simple low fidelity manikins and task trainers. The clinical setting only affords the student the opportunity to observe clinical decision making, to shadow the clinical judgment of the nurse they follow. They have some opportunity to demonstrate what they have learned in theory class and lab, but the limitation of their role as students does not give them the freedom to make clinical decisions and follow through with their impact.  Only in simulation does the nursing student get to “practice nursing” in all its aspects. They bring the cognitive and psychomotor to a simulated patient while applying the affective learning domain to the clinical decisions and judgements they make in the simulation.

Because of the unique benefit of simulation to nursing students, it is crucial it is implemented in a way that is thoughtful and mindful of its effect on students. Anxious and uncertain students who feel ambushed by the experience miss out on a rich learning opportunity. Debrief in those situations focuses on their feelings about the simulation (fear, anxiety, embarrassment, and lack of confidence), not the process of clinical decision making, the rationale behind decisions and actions and the management of consequences. Their memory of sim lab will be negative and associated with stress, dread and anxiety. These are all barriers to the learning process, meeting the objectives of the scenario and retention of the intended learning outcomes.

Simulation is an experiential learning process and preparation is an essential element of that approach Preparing students in a mindful way, one that is clear about the objectives, goals and expectations of the scenario affords the student tools to approach the scenario focused on the clinical decision making process and their own use of clinical judgement. They come out feeling confident, able to apply the lessons learned in the scenario to their future practice and non-judgmentally reflective of their own behaviors.

This is based on my own observations as a simulation instructor/facilitator of over 7 years, my knowledge of the simulation literature, my understanding of teaching/learning theories and anecdotal evidence from simulation peers. My own teaching philosophy is grounded in the idea that nursing education is a transformational process for students. The educator is the facilitator of that process and has a powerful role in constructing learning opportunities that have a great effect on the growth and development of the student into a nurse. If done haphazardly or without consideration to the impact- especially in simulation- great harm can come to that student. Deep scars and trauma can be left behind, challenging the confidence, growth and positive transformation of that student. For this reason, I am researching the practices of pre-briefing in nursing education.  I feel it is crucial for a structured and theory based framework of the essential elements of pre-briefing be developed so nurse faculty can have guidance in implementing simulation based education. Pre-briefing is a critical element of simulation design and much like the focus on debriefing techniques and the safety of the simulation environment and the debrief, and I feel we must be just as careful, deliberate and structured in designing and implementing the pre-brief.


More on learning theories and nursing education.

Best practices in experiential learning.

Simulation based constructivist approach for education leaders.