Just call me Dr. Cougsky

So I did it! I finally finished my PhD. I successfully defended my dissertation, entitled: “A survey of simulation prebriefing practices in prelicensure nursing programs in the United States” on May 21, 2021. It’s pretty amazing to be done and feels a bit unreal.

Among my many post-grad to-dos, updating this blogfolio is on my list, and my resume. And getting my other two manuscripts published. What? What manuscripts you say? Well, I may have mentioned this before, but my dissertation was the 3 paper approach. I wrote my chapters as stand alone journal articles. One has already been published:

Ludlow, J. (2020). Prebriefing: a principle-based concept analysis. Clinical Simulation in Nursing. In Press. https://doi.org/10.1016/j.ecns.2020.11.003

(that’s weird to see my OWN name in citation format!)

My other 2 articles are the findings of a national prebriefing survey with almost 300 responses from prelicensure nursing programs. Very interesting information came out of this survey- and a better understanding of the faculty perspective of prebriefing and preparation.

Now that I am done with school (a 7 year journey, BTW) I plan to rest my brain for a bit. Focus on my work (aka my day job), and get myself grounded again. But that doesn’t mean I am done. OH no, expect more from me!

But for now— GO COUGS! GO DAWGS!

Coug (WSU) + Dawg (UW) = CATDOG (or “Cougsky”!)

Healthcare Simulation Week 2020! Reflections of a simulationist.

When I discovered simulation, I was first intrigued by the technology, l’ll admit. And the overall coolness of it… but it led me on a path that transformed what teaching means to me… and to the learner.

I went into teaching at first… I thought… because I like to hear myself talk. OK, not exactly but, you know, I wanted to share all my knowledge. Translate information, facts and the skills of being a nurse through me and to students. I envisioned myself as the wise, honored teacher. The Sage on the Stage… those were the teachers I learned from in my life, those I respected and emulated.

But then, I discovered simulation.  I was first intrigued by the technology, l’ll admit. And the overall coolness of it… but it led me on a path that transformed what teaching means to me… and to the learner.

My first simulation experience was as an observer… I actually- literally stumbled onto it… I was at the training center for Madigan Army Medical Center (now known as the Charles A. Andersen Simulation Center) earning my ACLS instructor certification. I was working as a floor nurse at MAMC at the time, and just beginning to nurture the teacher within.

My first exposure to simulation- I stumbled into a room with this going on!

While I was in class, I was distracted by loud noises from another room… shouting, moaning,  explosions. I slipped out of my classroom and wandered the halls until I found the source of the commotion. A dimly lit room, camo nets hanging from the ceiling, darkness punctuated by strobe light flashes, the sound of mortar explosions and someone groaning in pain. I look down to see a man on the ground, covered in blood, the source of the groans. It took a minute for me to realize he wasn’t real… that I’d stumbled into a well crafted battle injury scenario training space.

I thought to myself, “wow! What a way to learn”… to be immersed in the reality of a situation (to learn later that’s fidelity) in a place where mistakes and  learning have no risk and cause no harm (to learn later that’s psychological safety) with the opportunity to reflect on actions taken and how to improve (to learn later that’s debriefing).  I was hooked!

I went back to my ACLS class and inadvertently created and ran my very first sim scenario. I had to teach the asystole algorithm.  So I created a scenario with a witnessed asystole patient, who the learners go on to discover was DNR after they initiated resuscitation… it was fun to see the progression of the scenario (I got to use a Sim Man too!). And have a meaningful discussion about the challenges of this algorithm and the ethics of resuscitation. 

Fast forward many years from that day. I’ve run hundreds of simulations, in a variety of fidelity levels, in all sorts of settings, with the complete gamut of technologies and I have taught hundreds of nurses and health care providers.

And I no longer want to be that Sage on the Stage. I will admit, I am finding myself doing a lot of webinars and other types of presentations still have me up there, speaking and sharing ideas. But still, my goal is to awaken knowledge in others, not pour my vast amount of wisdom unto their heads. As a simulationist, I guide learners through experiences that allow them to determine their own learning. There’s a whole host of learning theories and teaching methods this approach supports from constructivism to heutogogy. But what reinforces it to me is seeing the results. Seeing learners gain insight and awareness during a robust and learner-focused debriefing.  I have come to realize my skill as a sim facilitator and debriefer is critical to guiding them to creation of knowledge and hitting those crucial levels in learning taxonomy through experiential learning.

Bloom’s Taxonomy AND Vygotsky’s Zone of Proximal Development to explain the importance of preparation for simulation. How nerdy is that?!

I now am privileged to be in a leadership position and supporting a program that provides simulation experiences to learners. I am also training up the next generation of simulationists. Simulation is still fun to me, though. I love creating real life scenarios,  making the environment realistic, helping learners suspend disbelief and seeing them get caught up in the excitement of a challenging patient care situation, a communication challenge, a team based intervention or disaster scenario.  When I see the wheels turning in their heads, the self-reflection turned on and,  in that psychologically safe environment, the ability to learn from doing things right AND making mistakes, I am inspired by them!

Me, presenting a webinar about how we are bringing students back to the Simulation Center during the pandemic.

I became a nurse, like many have before me, to “help” others. That extended to my teaching, to “teach” others. I have learned, though, we help others the best by not doing for them or “to” them… but doing with them. The path to healing belongs to the patient and the path to learning, to the learner. As a nurse I have had the honor to walk alongside folks on their path to wellness,  and now, as a teacher,  I am privileged to guide learners through immersion experiences from which they emerge as safe, competent healthcare providers.

Prebriefing is STILL important!

It has been a while since I’ve posted- which is how I pretty much start every post here. I think I will someday really get to dedicate time to this site, once I finish school (maybe in a year?) and I can focus some good energy here. I am working on a post based off of a presentation I did recently, but I have other priorities.

Such as:


Which is happening this week. So I am supposed to be working on my slide deck, but I needed a break. Here’s my abstract:


And a really important update I should also make: I have a new job! I am now the Director of Simulation for the University of Washington School of Nursing! Which is an amazing opportunity! I am less than a month in, and working to figure things out as our university (and the nation) moves all education online for at least the rest of this academic year. So right into the fire! But I love a challenge and I cannot say enough positive things about the dedicated faculty and support staff, along with University and SoN administration. We are all in this to ensure students are supported and have the opportunity to learn.

But now I am thinking/developing a prebriefing approach to online and virtual simulations in response to the shift in our educational delivery methods.

OK for real: I am working on my Prelim Defense slide deck. And on that note, I will sign off. And hope to be updating this site again someday! I am officially a CATDOG. (WSU student- Cougars, UW Staff- Huskies) Also known as a #cougsky



Another overdue update!

It’s been a while since I’ve posted here, but that’s only because I have been busy! I am working at Virginia Mason as a Education Program Manager . It’s a job that is a little bit of everything, but mostly a chance for me to use my simulation knowledge to support the development and improvement of training and education here.

As for my academic pursuits, I am continuing on the course. I am going to be a pilot case for WSU’s School of  Nursing PhD by manuscript approach. Here’s my proposal in a nutshell:

Aim and Research Questions
The overall objective of this PhD by manuscript is to develop a survey to collect and evaluate data on the prebriefing practices of pre-licensure nursing programs in the United States which will to inform nursing education practice. The first manuscript will be a principle-based concept analysis that will explore prebriefing in the literature. Based on these findings, a survey will be developed that includes both quantitative and qualitative questions. It will be distributed to pre-licensure nursing programs in the United States that are using simulation in their curriculum. The second manuscript will address quantitative findings. The third manuscript will address the qualitative findings.

Purpose: To explore the simulation prebriefing practices (including preparation) of pre-licensure nursing programs in the United States.
1. Assess current practices in simulation prebriefing within pre-licensure nursing programs in the United States.
2. Better understand the activities that occur in the pre-simulation period within pre-licensure nursing programs in the United States.
3. Determine how nurse educators in the United States are preparing their pre-licensure students for simulation-based learning.
4. Assess for alignment in prebriefing practices with the recommendations in the INACSL Standards.

At this point, I am finishing up my first manuscript and preparing to format it for submission. I will then work on a draft of my survey in preparation for my prelims in March. After that it will be fast and furious as I get through IRB and try to get the survey out before the academic school year ends. I am hoping to collect data this spring, summer and some of fall. My goal is to defend in Spring of 2021. Wish me LUCK!



I’ve not been here recently because so much has been happening!

The biggest update to share is that I have accepted a position as the education program manager at the Jones Learning, Innovation and Simulation Center at Virginia Mason Medical Center in Seattle, WA! It is a brand new role for the organization and for me.

As a result of this transition, I have some work to do to update this blogfolio and align it with my current work. I do feel keeping my academic experience and nurse educator work here is relevant, but I plan to acknowledge my new role and what it means for my teaching philosophy.

I’m making progress with my first 3 chapters, hoping to finish up chapter 2 this month and be in a position to take my prelim exam in Spring. I may share some sneak peeks of progress in the near future!

Looking forward to attending IMSH 2019 with my new team members, learning the ways of VMPS, and finding new ways to bring learning to life through simulation!

BOISE 2018!

This year, I got tFishhe chance to return to the Boise NLN simulation conference, hosted by Boise State University. This is my third time here. Added bonus: I was a presenter! Such an exciting opportunity.   I presented the findings of my principle-based concept analysis of prebriefing, which I shared here.

I brought along some of my co-workers from the hospital, too. I was nervous they might not find anything interesting, but the program contained a variety of sessions and a few that applied to nursing residencies and other more general topics.

I was a bit nervous about my presentation, too. Mostly that no one would show  up because… well a concept analysis?? How boring! OK! So that didn’t happen. Most of the room was full! Then I worried the topic would not be as interesting to them as it was to me. But luckily again! Most people were engaged, and during the break out/discussion session as I wandered the room, people were excited to think and discuss research ideas for prebriefing. Finally I had about a dozen folks who were interested in getting a copy of my slides and references!   (click  if you want to see them!). I was worried I’d go over on time, and I did cut it a bit too close (and went over by a few minutes), but the group participation was worth it.

I will admit I have been looking forward to getting to speak and share at conferences for a long time. I had found I was reaching a saturation point at sim conferences, where I felt it was time for me to start contributing. So I am super excited that I had this opportunity to share. And while it’s not as comfortable for me as teaching in front of a class, speaking in front of 40 people who are a different level was not as scary as I expected.

I am also realizing how much I miss  being hands-on with simulation. While I am working with my team at Valley to add more sim activities and interactive learning in general to our educational materials, I do miss the challenge and reward of navigating learners through the realistic experiences of simulation and facilitating their learning through an effective debrief session.

Simulation takes deliberate practice, with mindful planning,  action  and evaluation. I am glad to see how far we’ve come in nursing with this learning tool. I am sad to see we are still finding under supported teams, often single faculty, trying to provide a high quality experience- at risk of burn out and potential eventual deterioration of quality… I do hope academic institutions will finally figure out how to appropriately compensate simulation educators and provide them the resources necessary to provide simulation that will give students those critical learning opportunities they are not getting in clinical.

We will see…


It’s getting real now, y’all

It is not enough to know what you want to research or even your theoretical framework, you must also know- what you want to do, how you want to conduct the research.

So I finished my course work last semester. This semester I took a seminar class to prepare for my prelim. In my program the prelim exam is not an actual test, but a presentation of your proposal (chapters 1, 2, and 3 of the dissertation), in which you are grilled by faculty and students and of course your committee. I am nowhere near ready for that, as I am just beginning to figure out what I want to do.

And I am way overdue with an update here. It has been a bit of a journey to get here. In summer 2014, I started this program with pretty much no idea what I was going to research, but knowing something related to nursing education. I bounced around and explored a variety of topics- from nursing faculty’s informatics competency, to student’s activities on the internet (that was a fun foray into the world of digital ethnography), and slowly moved towards simulation, settling on prebriefing (PB). It is not enough to know what you want to research or even your theoretical framework, you must also know- what you want to dohow you want to conduct the research. Which has been my challenge.

I have been frozen in a way because I could not come up with a plan that seemed feasible. Thinking of experimental research is overwhelming. There are no ready-made data sets collected that I can access, and while it is a good thing that the literature in PB is rather limited (leaving me room to do some work), it also means there is a lack of examples to follow.

It was also challenging that my program had gone through changes, my committee has pretty much dissolved except for one stalwart member who has stood the test of time.  I struggled to articulate my thoughts in a way that could present a reasonable proposal. My committee might not be experts in my topic, but they must understand it and its importance. Through some reflection and the support of a mentor who has done work in the area of PB, I was able to put together a plan and share it in the form of my “elevator speech”:

Prebriefing is considered an important aspect of simulation design, however, there are no theory-based models available for nurse educators to use when developing simulation learning experiences for their students. My research goal is to design and pilot test a simulation prebriefing model based on cognitive load principles which will increase germane load and manage the limited working memory of nursing students who participate in simulation learning experiences. Using a revised version of a cognitive load measurement tool which has been previously used with nursing students in simulation, I will compare the cognitive load of nursing students who receive the cognitive load theory based model of prebriefing to those who receive a conventional prebriefing. In addition, I will do some reliability testing of the revised tool.

 Now I am working to turn this into a chapter one. I already realize my problem statement, aims and research questions are still weak and scattered. I hesitate to commit as I am just not sure how I will operationalize this plan. Will I take over a sim lab somewhere and allow students to come and let me try my intervention (theory based prebrief) out on them, and compare their scores on a cognitive load survey? That’s what I imagine, but then my brain freaks out as I think of the logistics. It may be too much.

But I am counting on the expertise of my committee to guide me to something reasonable and not too far away from what I am looking at. I have spend a lot of time thinking about this topic, reading and learning the theory and collecting literature. Talking with my expert in the topic has also helped.

I am aiming to have my first 3 chapters done by end of fall 2018/early spring 2019 and defend my proposal sometime in Spring Semester 2019.  Depending on how I collect my data and what that looks like, I might be on track to defend my final dissertation by fall 2020. While it won’t be “before I turn 50” as I had hoped, it will be while I am “still 50” which is totally OK!

I sort of remember nursing school

Another assignment that I figured would be nice to share here.

The book I am referencing is

Benner, P. E., Sutphen, M., Leonard, V., & Day, L. (2010). Educating Nurses: A Call for Radical Transformation. San Francisco: Jossey-Bass.

Educating Nurses was published 10 years after I graduated, yet my experience has similarities to the descriptions in the book.  In all honesty, it is tricky to reflect back on my undergrad without the bias of my own experience as a nurse educator. In fact, much of my motivation to study nursing education and become well versed in it was a result of my perception of my own educational experience- and my continued assessment of the state of nursing education while working as a full-time faculty in ADN and RN-BSN programs.

I went to nursing school at a private Baptist college in Texas., University of Mary-Hardin Baylor (UMHB). I was not Baptist, but it was the closest BSN program. I already had my AA in English and Music and when I decided to study nursing instead, I figured I should get my bachelors instead of another associate’s degree.

I took pre-req courses from a variety of community colleges- from Kentucky, Oklahoma, California and Texas. I was the ultimate transfer student. I took more than I needed because I did not what program I would apply to (or where I was going to live even- Army life) so I went in with a very solid foundation.  I think I only took one or two non-nursing classes at UMHB. Instead I had transcripts from 5 different schools. And I was a nontraditional student in that I was in my late 20s with two small children and my husband was active duty army.

So, with all that, my only goal in that program was to get done. I came in with a lot of pathophysiology knowledge (I used to read the Merck Manual as a teenager for fun) and a solid science- and liberal arts background. There was not as much of a crunch of content into our brains as things were more spread out over the curriculum. That’s in contrast to the ADN program I taught at- that concept that nursing education is additive is SO true, every year it seemed we added more material and never felt like we could let things go.  As a student in my BSN program, we did have mostly lecture (overheads not powerpoints!) and multiple choice exams. And usually one written assignment per semester. That was how the diadatic content was covered.

My favorite class was our senior leadership class, I think the instructor enjoyed teaching it also. She had an MBA and marched to her own drum. And it was not “life or death” content, so she could have fun with it- it was very much applied knowledge- teaching presentation (I made overhead slides!), a change project on our assigned units (mine was developing a policy about whose responsibility it was to change out full sharps containers). Overall there were other elements presented in the book that occurred in my program: team teaching, heavy emphasis on the NANDA diagnoses and all the crazy strict rules about how to write a nursing diagnosis, lots of sage on the stage style lecturing and the occasional game to make things interesting.

My clinical is even harder to recollect. I was not paying attention to how I was being taught and I was kind of on survival mode most of the time (my husband was deployed to Korea my entire senior year). How much my instructors took time to question me and help me find learning opportunities was completely lost on me. I showed up exhausted from staying up late, after my small children went to bed, making my drug cards and getting up way too early. I honestly cannot remember a single post conference. I have a blur of a few key moments- putting a foley in a small child, who they thought had Kawasaki disease and she had a terrible rash all over her peri area, yet no one guided me to consider NOT putting iodine on that raw tender skin. Now I know I could have used soap and water.  I got in big trouble taking a Dr. up on his invitation to observe a circumcision during my OB rotation- I still have no idea why it upset my instructor so much. That was one of those clinicals where our hands were tied and all we could do is observe anyhow! There was some bullying by faculty in that program for sure, but also some kind and compassionate instructors. I also struggled with feeling comfortable taking care of patients and asking them all the questions on our assessment paperwork. They were so tired, miserable and in pain. And I was supposed to ask them about their sex life? Finally, I have a distinct memory of working up a sweat while trying to put TED hose on a knee replacement patient. That was most likely because of the terrible, hot, impractical, polyester uniform, complete with purple apron, we had to wear.

I spent most of my clinicals feeling terrified and unsure of what I was doing. The instructors overall (with a few exceptions) were kind and supportive. I think some of my anxiety stemmed from the fact that while I had a great deal of knowledge, I had very little patient care skill or experience. And our lab experience was dismal to say the least. This was pre-simulators and we did not even have mannikins to practice on. The only hands on practicing we had was assessment on each other (in our sports bras, with the 2 boys in the class sent to another room) and injections – of saline into our thighs.  Everything else was talked about and we hoped to get a chance to see it in action and maybe try it out.  I went into nursing terrified of doing any skills… and eventually became a skills lab instructor. What a way to face my fears!

So reading Benner’s book, I mostly find myself going, “yup, seen that, did that, still do that” when they discuss some of the challenges in nursing education. I think my own experiences as a nursing student were what drove my obsession with giving my students a good solid lab experience, yet balanced by understanding I could teach them everything and allowing some things to fall away for other things to move in (for example no longer testing trach care in exchange for some informatics content).

Beginnings of a concept analysis

This principle-based concept analysis aims to examine prebriefing, a component of simulation in nursing education.

As an assignment for my nursing theory class, we had to complete a principle-based concept analysis. I felt like I mostly had no idea what I was doing, but it did really help me understand my topic better and begin to see the gaps, conflicts and lay the foundation for my literature review. I have gotten feedback that implies this could be turned into something I could submit to a journal. So this should be considered only a draft version that I am sharing here. Please respect the ownership of my ideas. Thank you.


In 2004, Gaba described simulation as a “technique…to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner” (p. 12). This definition continues to be referenced as the most accurate description of simulation in health care (Alexander et al., 2015). Simulation is now considered to be an integral part of nursing education programs and has its own standards of best practice and a body of research evidence that supports its effectiveness (Jeffries, 2016; Lavoie & Clarke, 2017).
This principle-based concept analysis aims to examine prebriefing, a component of simulation in nursing education. Prebriefing is considered an essential element of simulation design (INACSL Standards Committee, 2016c). The International Nursing Association for Clinical Simulation and Learning (INACSL) Standards of Best Practice: Simulation SM define prebriefing broadly as “an information or orientation session immediately prior to the start of a Simulation Based Experience in which instructions or preparatory information is given to the participants.” (INACSL Standards Committee, 2016b, p. S43)
The definition also includes an emphasis on the role of prebriefing to provide a psychologically safe environment for learners (INACSL Standards Committee, 2016b). Despite this standard definition, prebriefing as a concept appears varied in the literature. Many educators will provide an orientation to the equipment and the space and process of simulation, but provide little information about the scenario itself, while other educators refer to preparation in the form of care planning, written assignments and role modeling as prebriefing (Page-cutrara, 2014a). There is also lack of consensus regarding how much information to provide to the participants about the simulation in this phase (Page-cutrara, 2014a). Unlike debriefing, which has a strong body of literature describing its best practices, theory, and framework, prebriefing is just beginning to appear as its own topic in the simulation literature. It lacks a well-defined framework and is considered a top priority research topic in nursing simulation (Fey & Chse, 2016; The International Nursing Association for Clinical Simulation and Learning, 2017).
This principle-based concept analysis is based on a review of the current state of the science of prebrief as reflected in the current literature. The “Search IT” function of Washington State University’s (WSU) Library searches the entire WSU library catalog in a variety of disciplines. This search tool found the following number of results for each term and combination of terms used: “prebrief” (102) “prebrief nursing simulation (34)”, “pre-brief, simulation (47) and “prebrief, nursing, simulation, education (232)”. Combinations of these terms, along with alternative terms such as “healthcare” provided similar results. Applying non-nursing and non- healthcare filters, yielded a small number of findings in the following disciplines: aircraft safety (8) and military (9), of which approximately half were duplicates. The most useful search strategy used the Boolean “AND” with the terms “prebrief”, “nursing”, “simulation”, “education” which yielded a total of 47 articles and dissertations. Of these, based on title and review of the abstract, about 13 were relevant to prebriefing in nursing education and simulation.
Searching the multidisciplinary literature in this way provides an expanded range of results, however, in this analysis prebriefing is a concept specific to simulation in nursing education. Since simulation is a specialized field in healthcare education, another approach used was to search the two peer reviewed journals that are dedicated to simulation in healthcare: Clinical Simulation in Nursing and Simulation in Healthcare. Focusing on these specific journals reduces the need to for additional terms such as “nursing education” or “healthcare education”. A search of the term “prebrief’ yielded 78 results and “pre-brief” yielded 387 results from Clinical Simulation in Nursing. Searching Simulation in Healthcare for “pre-brief” and “prebrief” only yielded 4 results, but the term “briefing” provided 80 results. These results were then narrowed down by title and abstract content and provided the published resources used in this analysis.
It is important to note that in 2016, two concept analyses of prebriefing were published. Neither author used the principle-based concept analysis approach, but both did acknowledge a gap in the literature regarding the standardization of prebriefing practices and the use of the term (Chamberlain, 2015; Page-Cutrara, 2014b). This principle based approach intends to explore the use of prebriefing in simulation literature from a different perspective by exploring it within four principles: epistemological, pragmatic, linguistic and logical (Penrod & Hupcey, 2005).
Epistemological Principle
The concept of prebriefing continues to mature epistemologically and develop its own distinction within the knowledge base of simulation (Penrod & Hupcey, 2005). The term was introduced and defined 2011, when INACSL published the first version of the Standards of Best Practice in Simulation (Sando, Faragher, Boese, & Decker, 2011). In those 2011 Standards, prebriefing was defined in Standard I: Terminology as an information session held before the simulation that provides instructions, preparatory information, and orientation to equipment (The INASCL Board of Directors, 2011).
In the next version of the Standards in 2013, prebriefing was defined similarly and was also included in Standard IV: Facilitation, under Criterion 1, as a facilitation method that occurs before the simulation and includes orientation to the equipment, ground rules to provide a psychologically safe environment, expectations, and background information on the scenario (Franklin et al., 2013) . In 2015, the Standards Committee added two additional standards. One of these was the Design Standard, which introduced prebriefing as “briefing” in Criterion 7 (Lioce et al., 2015). Participant preparation was delineated from the orientation aspects of briefing in Criterion 10: Participant Preparation (Lioce et al., 2015). This is the first mention of providing content-related activities to prepare the learner for the simulation in addition to the logistical orientation of (pre)briefing in the Standards.
In the most recent iteration, published in 2016, the Committee returned to the term “prebriefing”. Prebriefing and participant preparation are again addressed in two separate criterion of the INACSL Standards of Best Practice: SimulationSM Simulation Design Standard (the Standards Committee has removed the numbering of standards and now include a servicemark designation). Criterion 7 describes prebriefing as a required orientation phase of simulation, similar to its early definition (INACSL Standards Committee, 2016c). It is described as a structured and consistent element of simulation that includes orientation to equipment, space, time and other logistical aspects of the simulation (INACSL Standards Committee, 2016c). In addition, behavior expectations, establishing trust and ground rules, and a fiction contract are also part of the prebriefing. Criterion 10 addresses participant preparation, however it is not considered a phase in the simulation itself. It is discussed in the standard after the debrief and evaluation phases, as if an afterthought to the process. Its placement there is strategic, as the INACSL Standards of Best Practice: SimulationSM Simulation Design standard recommends that the preparatory materials are developed after the simulation is designed. Criterion 10 states that the preparatory materials aim to “address the knowledge, skills, attitudes, and behaviors that will be expected of the participants during the simulation-based experience” (INACSL Standards Committee, 2016c, p. S8). These materials should be completed prior to the prebriefing and may include didactic sessions, reading, concept maps, quizzes, and other activities that will enable the learner to be successful at meeting the simulation outcomes (Boese et al., 2013; INACSL Standards Committee, 2016c).
The 2016 version of the INACSL Standards of Best Practice: SimulationSM Facilitation brings preparation and prebriefing together in Criterion 3 (INACSL Standards Committee, 2016a). This Criterion is the most descriptive and proscriptive in regards to prebriefing and participant preparation thus far. In this Criterion there a directive to ensure participants have completed preparatory materials and an expansion of the content of prebriefing to include a minimum of six elements (INACSL Standards Committee, 2016a).
It would appear that, conceptually, prebriefing is a logistical part of the simulation based on these descriptions and represents a time to assure participants of their psychological safety; develop familiarity with the equipment; and clarify roles, rules, and expectations. Participant preparation for simulation, including assignments, reading, and didactic content, is considered a separate phase and aspect of simulation design and facilitation. However, this is reflected in the most recent literature. For example, in a 2017 study that looked at the impact of prebriefing on the performance of participants, the prebriefing was “… structured by concept mapping-type activities and guided reflection” (Page-Cutrara & Turk, 2017, p. 78). Another example is Chamberlain’s (2017) comparison of four different combinations of preparation for simulation, of which there were two preparation activities, both referred to as prebriefing: learning engagement and orientation. In their evaluation of the state of the science of anxiety in simulation, Shearer (2016) refers to the role of “preparation” in addressing the “Unknown” in simulation. The author states, “the use of standard practice in regard to preparation may assist the student to achieve the best possible outcome” (Shearer, 2016, p. 553), identifying a need for a standard preparation practice which is not specifically described as prebriefing. This lack of distinction between prebriefing and participant preparation is pervasive in the literature and demonstrates a lack of maturity in the concept.
Pragmatic Principle
This inconsistency between the standard-based description of the concept of prebriefing and its manifestations in the literature present a pragmatic challenge as the concept is identified by experts in a variety of ways (Penrod & Hupcey, 2005). In 2016, the same year the current INACSL Standards of Best Practice: SimulationSM were published, McDermott published a Delphi study that reviewed the concept of prebriefing with simulation experts. According to this study, clear consensus is still lacking as to what exactly prebriefing is; however, the experts described prebriefing as having three phases: planning, briefing, and facilitating (McDermott, 2016). The planning phase is when learning activities are provided to prepare the participant. To these experts, participant preparation is not considered a separate element of the simulation, but an early phase of prebriefing (McDermott, 2016).
Another example of a deviation from the standard definition of prebriefing as orientation only is the use of role-modeling as a prebriefing technique. Multiple studies have used forms of expert role modeling as simulation preparation: some refer to the intervention as part of the prebriefing, while others make no mention of prebriefing but include the role modeling intervention as part of the orientation phase of the simulation (Anderson, LeFlore, & Anderson, 2013; Aronson, Glynn, & Squires, 2013; Coram, 2016; Johnson et al., 2012; Stockert et al., 2015).
Linguistic Principle
The terms prebriefing, brief, pre-simulation preparation, pre-scenario work, preparatory activity and orientation appear in the literature referring to the preparatory activities that occur before a simulation experience (Chamberlain, 2015, 2017; Page-Cutrara, 2015; Tyerman, Luctkar-Flude, Graham, Coffey, & Olsen-Lynch, 2016). Of these terms, linguistically, prebriefing is consistently context bound to the activities that occur in the period preceding the simulation scenario (Penrod & Hupcey, 2005).
Many articles mention prebriefing when describing the activities that occur before the simulation scenario used in a study. In a study using a medication safety simulation, the authors state, “all students received standardized prebriefing, including objectives, case overview, and preparatory work. The preparation included readings and review questions. In addition, students were oriented to their surroundings and given the opportunity to ask questions” (Mariani, Ross, Paparella, & Allen, 2017, p. 213). Another example is less descriptive but placed the prebriefing before the scenario, “learners in both types of simulations received a standard prebriefing” (Luctkar-Flude, Wilson-Keates, Tyerman, Larocque, & Brown, 2017, p. 266). Some authors do separate the preparatory work from the prebriefing orientation in their descriptions, yet it still occurs in the context before the scenario. For example, in a study comparing the sequencing of simulation and hospital based experiences, the authors stated, “activities… included orientation to the simulation room and manikin, prebriefing, a prequiz, the patient care scenario, and debriefing” (Woda, Gruenke, Alt-Gehrman, & Hansen, 2016, p. 530). While there is a lack of consensus in the literature as to what specific components comprise prebriefing, conceptually it is a component of the activities occurring prior to the simulation scenario.
Logical Principle
Prebriefing is an element in many teaching and learning theories as they are applied, pedagogically, to simulation. Within these theories, prebriefing — whether it is orientation or other activities — remains clear as a concept of preparation (Penrod & Hupcey, 2005). Much like simulation in general as a pedagogical modality, prebriefing fits conceptually into many learning theories as such as Kolb’s Experiential Learning theory, adult learning theory, Bandura’s Social-Cognitive theory, situated cognition, cognitive load theory, brain-based education, and constructivist theories in the role of preparation to facilitate learning (Bethards, 2014; Cardoza, 2011; Clapper, 2015; Kaakinen & Arwood, 2009; Onda, 2012; Paige & Daley, 2009; Poore, Cullen, & Schaar, 2014; Zigmont, Kappus, & Sudikoff, 2011).
Cognitive load theory is an excellent example. In this theory, the concept of prebriefing is an essential element that can diminish the learner’s extraneous cognitive load, establish prerequisite knowledge and allow the learning experience of simulation to be committed to the learner’s working memory (Fraser, Ayres, & Sweller, 2015). Prebriefing provides orientation to the environment and equipment, establishes psychological safety, and increases the learning capacity of the participant by decreasing anxiety about the situation and distraction (Fraser et al., 2015; Hessler & Henderson, 2013; Janzen et al., 2016; Josephsen, 2015; Reedy, 2015; Rudolph, Raemer, & Simon, 2014). As a preparatory activity, prebriefing fits nicely into the framework of cognitive load theory.
This principle-based concept analysis shows that prebriefing is context bound to the time period preceding simulation scenarios and is clear as a concept in many learning theories; however, it is not yet a distinct concept in the literature, nor does it manifest itself consistently. References to prebriefing in the literature blur the line between prebriefing and participant preparation. The goal of future research on prebriefing should be to unify these elements and expand the concept of prebriefing beyond orientation and into a theory driven, structured process that takes into account the needs of the nursing student as a learner acting in the role of novice nurse in simulation. Adopting McDermott’s (2016) expert-generated idea of phases of prebriefing unites preparation with prebriefing and allows for the development of a phase-based, structured framework that would establish psychological safety, decrease anxiety and extraneous cognitive load, and increase learner engagement with prerequisite knowledge.

References (Apologies: not properly formatted in any way)
Alexander, M., Durham, C. F., Hooper, J. I., Jeffries, P. R., Goldman, N., Kardong-edgren, S. S., … Tillman, C. (2015). NCSBN simulation guidelines for prelicensure nursing programs. Journal of Nursing Regulation, 6(3), 39–42. http://doi.org/10.1016/S2155-8256(15)30783-3
Anderson, M., LeFlore, J. L., & Anderson, J. M. (2013). Evaluating videotaped role-modeling to teach crisis resource management principles. Clinical Simulation in Nursing, 9(9), e343–e354. http://doi.org/10.1016/j.ecns.2012.05.007
Aronson, B., Glynn, B., & Squires, T. (2013). Effectiveness of a role-modeling intervention on student nurse simulation competency. Clinical Simulation in Nursing, 9(4), e121–e126. http://doi.org/10.1016/j.ecns.2011.11.005
Bethards, M. L. (2014). Applying social learning theory to the observer role in simulation. Clinical Simulation in Nursing, 10(2), e65–e69. http://doi.org/10.1016/j.ecns.2013.08.002
Boese, T., Cato, M., Gonzalez, L., Jones, A., Kennedy, K., Reese, C., … Orum, J. C. (2013). Standards of Best Practice: Simulation Standard IX: Simulation Design. Clinical Simulation in Nursing, 9(6s), S22–S25. http://doi.org/10.1016/j.ecns.2015.03.005
Cardoza, M. P. (2011). Neuroscience and simulation: An evolving theory of brain-based education. Clinical Simulation in Nursing, 7(6), e205–e208. http://doi.org/10.1016/j.ecns.2011.08.004
Chamberlain, j. (2015). prebriefing in nursing simulation: a concept Analysis Using Rodger’s Methodology. Clinical Simulation in Nursing, 11(7), 318–322. http://doi.org/10.1016/j.ecns.2015.05.003
Chamberlain, J. (2017). The Impact of simulation prebriefing on perceptions of overall effectiveness, learning, and self-confidence in nursing students. Nurisng Education Perspectives, 38(3), 119–125. http://doi.org/10.1097/01.NEP.0000000000000135
Clapper, T. C. (2015). Cooperative-based learning and the zone of proximal development. Simulation & Gaming, 46(2), 148–158. http://doi.org/10.1177/1046878115569044
Coram, C. (2016). Expert role modeling effect on novice nursing students’ clinical judgment. Clinical Simulation in Nursing, 12(9), 385–391. http://doi.org/10.1016/j.ecns.2016.04.009
Fey, M. K. (2016). Leading the way in simulation research. Clinical Simulation in Nursing, 12(3), 85–86. http://doi.org/10.1016/j.ecns.2016.01.001
Franklin, A. E., Boese, T., Gloe, D., Lioce, L., Decker, S., Sando, C. R., … Borum, J. C. (2013). Standards of Best Practice: Simulation Standard IV: Facilitation. Clinical Simulation in Nursing, 9(6s), S19–S21. http://doi.org/10.1016/j.ecns.2015.03.005
Fraser, K. L., Ayres, P., & Sweller, J. (2015). Cognitive load theory for the design of medical simulations. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 10(5), 295–307. http://doi.org/10.1097/SIH.0000000000000097
Gaba, D. M. (2004). The future vision of simulation in health care. Quality and Safety in Health Care, 13(suppl_1), i2–i10. http://doi.org/10.1136/qshc.2004.009878
Hessler, K. L., & Henderson, A. M. (2013). Interactive learning research: Application of cognitive load theory to nursing education. International Journal of Nursing Education Scholarship, 10(1), 1–9. http://doi.org/10.1515/ijnes-2012-0029
INACSL Standards Committee. (2016a). INACSL Standards of Best Practice: Simulation Facilitation. Clinical Simulation in Nursing, 12, S16–S20. http://doi.org/10.1016/j.ecns.2016.09.005
INACSL Standards Committee. (2016b). INACSL Standards of Best Practice: Simulation Simulation Glossry. Clinical Simulation in Nursing, 12, S39–S47. http://doi.org/10.1016/j.ecns.2016.09.005
INACSL Standards Committee. (2016c). INACSL Standards of Best Practice: SimulationSM Simulation Design. Clinical Simulation in Nursing, 12, S5–S12. http://doi.org/10.1016/j.ecns.2016.09.005
Janzen, K. J., Jeske, S., MacLean, H., Harvey, G., Nickle, P., Norenna, L., … McLellan, H. (2016). Handling strong emotions before, during, and after simulated clinical experiences. Clinical Simulation in Nursing, 12(2), 37–43. http://doi.org/10.1016/j.ecns.2015.12.004
Jeffries, P. R. (2016). Reflections on clinical simulation: The past, present, and future. Nursing Education Perspectives, 36(5), 278–279. Retrieved from http://search.ebscohost.com/login.aspx?direct=true%7B&%7Ddb=a9h%7B&%7DAN=118873021%7B&%7Dsite=ehost-live
Johnson, E. A., Lasatar, K., Hodson-Carlton, K., Siktberg, L., Sideras, S., & Dillard, N. (2012). Geriatrics in simulation: Role modeling and clinical judgement effect. Nursing Education Perspectives, 33(3), 176–180. http://doi.org/10.5480/1536-5026-33.3.176
Josephsen, J. (2015). Cognitive load theory and nursing simulation: An integrative review. Clinical Simulation in Nursing, 11(5), 259–267. http://doi.org/10.1016/j.ecns.2015.02.004
Kaakinen, J., & Arwood, E. (2009). Systematic review of nursing simulation literature for use of learning theory. International Journal of Nursing Education Scholarship, 6(1), Article 16. http://doi.org/10.2202/1548-923X.1688
Lavoie, P., & Clarke, S. (2017). Simulation in nursing education. Nursing Management, 3(4), 16–17.
Lioce, L., Meakim, C. H., Fey, M. K., Chmil, J. V., Mariani, B., & Alinier, G. (2015). Standards of Best Practice: Simulation Standard IX: Simulation Design. Clinical Simulation in Nursing, 11(6), 309–315. http://doi.org/10.1016/j.ecns.2015.03.005
Luctkar-Flude, M., Wilson-Keates, B., Tyerman, J., Larocque, M., & Brown, C. A. (2017). Comparing instructor-led versus student-led simulation facilitation methods for novice nursing students. Clinical Simulation in Nursing, 13(6), 264–269. http://doi.org/10.1016/j.ecns.2017.03.002
Mariani, B., Ross, J. G., Paparella, S., & Allen, L. R. (2017). Medication safety simulation to assess student knowledge and competence. Clinical Simulation in Nursing, 13(5), 210–216. http://doi.org/10.1016/j.ecns.2017.01.003
McDermott, D. S. (2016). The Prebriefing Concept: A Delphi Study of CHSE Experts. Clinical Simulation in Nursing, 12(6), 219–227. http://doi.org/10.1016/j.ecns.2016.02.001
Onda, E. L. (2012). Situated cognition: Its relationship to simulation in nursing education. Clinical Simulation in Nursing, 8(7), e273–e280. http://doi.org/10.1016/j.ecns.2010.11.004
Page-cutrara, K. (2014a). Use of prebriefing in nursing simulation : A literature review. Jounral of Nursing Education, 53(3). http://doi.org/10.3928/01484834-20140211-07
Page-Cutrara, K. (2015). Prebriefing in nursing simulation: A concept analysis. Clinical Simulation in Nursing, 11(7), 335–340. http://doi.org/http://dx.doi.org/10.1016/j.ecns.2015.05.001
Page-Cutrara, K., & Turk, M. (2017). Impact of prebriefing on competency performance, clinical judgment and experience in simulation: An experimental study. Nurse Education Today, 48, 78–83. http://doi.org/10.1016/j.nedt.2016.09.012
Paige, J. B., & Daley, B. J. (2009). Situated cognition: A learning framework to support and guide high-fidelity simulation. Clinical Simulation in Nursing, 5(3), e97–e103. http://doi.org/10.1016/j.ecns.2009.03.120
Penrod, J., & Hupcey, J. E. (2005). Enhancing methodological clarity: Principle-based concept analysis. Journal of Advanced Nursing, 50(4), 403–409. http://doi.org/10.1111/j.1365-2648.2005.03405.x
Poore, J. A., Cullen, D. L., & Schaar, G. L. (2014). Simulation-based interprofessional education guided by Kolb’s experiential learning theory. Clinical Simulation in Nursing, 10(5), e241–e247. http://doi.org/10.1016/j.ecns.2014.01.004
Reedy, G. B. (2015). Using cognitive load theory to inform simulation design and practice. Clinical Simulation in Nursing, 11(8), 355–360. http://doi.org/10.1016/j.ecns.2015.05.004
Rudolph, J. W., Raemer, D. B., & Simon, R. (2014). Establishing a safe container for learning in simulation. Simulation in Healthcare: Journal of the Society for Simulation in Healthcare, 9(6), 339–349. http://doi.org/10.1097/SIH.0000000000000047
Sando, C., Faragher, J., Boese, T., & Decker, S. (2011). Simulation standards development: an idea inspires . . . Clinical Simulation in Nursing, 7(3), e73–e74. http://doi.org/10.1016/j.ecns.2010.12.004
Shearer, J. N. (2016). Anxiety, nursing students, and simulation: State of the science. Journal of Nursing Education, 55(10), 551–554. http://doi.org/10.3928/01484834-20160914-02
Stockert, B., Heckeroth, C., Mccormack, C., Nguyen, T., Padilla, J., Vigil, C., & Willis, M. (2015). Improving recognition of adverse events in the icu using pre-briefing and high-fidelity simulation. Physiotherapy 2015, 101(1), 2015.
The INASCL Board of Directors. (2011). Standard I: Terminology. Clinical Simulation in Nursing, 7(4), S3–S7. http://doi.org/10.1016/j.ecns.2011.05.005
The International Nursing Association for Clinical Simulation and Learning. (2017). Grant opportunities. Retrieved June 23, 2017, from https://www.inacsl.org/i4a/pages/index.cfm?pageid=3293
Tyerman, J., Luctkar-Flude, M., Graham, L., Coffey, S., & Olsen-Lynch, E. (2016). Pre-simulation preparation and briefing practices for healthcare professionals and students: A systematic review protocol. JBI Database of Systematic Reviews and Implementation Reports http://doi.org/10.11124/JBISRIR-2016-003055
Woda, A. A., Gruenke, T., Alt-Gehrman, P., & Hansen, J. (2016). Nursing student perceptions regarding simulation experience sequencing. Journal of Nursing Education, 55(9), 528–532. http://doi.org/10.3928/01484834-20160816-07
Zigmont, J. J., Kappus, L. J., & Sudikoff, S. N. (2011). Theoretical foundations of learning through simulation. Seminars in Perinatology, 35(2), 47–51. http://doi.org/10.1053/j.semperi.2011.01.002




Appendix A
The following is a proposed theoretical framework based on this concept analysis integrates the three domains of learning into three phases of preparation:

The preparatory phase (cognitive domain) where learners prepare by learning about 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 experiment hands-on with equipment or examine the space the simulation will occur and become familiar with it. In this phase, they may review skills that may be required in the simulation whether it is auscultation of the manikin 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 review 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.