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)
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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.