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Promoting Excellence And Reflective
Learning in Simulation (PEARLS):
A Blended Approach to Healthcare Debriefing
Walter Ep...
Disclosure
• Eppich
– Center for Medical Simulation, Boston/USA
– Honoraria to teach on train-the-trainer courses with PAE...
Welcome & Introductions
Our basic assumption
• Everyone participating in training is
intelligent, capable, does their best, and
wants to improve
C...
Ground rules
Learning objectives
After this session, you will be better able to:
1. Identify three different educational strategies use...
Workshop Outline
• Introductions
• PEARLS overview
• Video exercises
– Self-assessment (e.g. Plus-Delta)
– Focused facilit...
Debriefing
• Facilitated reflection in
experiential learning1
• Involves “the active
participation of learners,
guided by ...
Debriefing
• Feedback and debriefing
an essential component of
simulation-based
education1,2
• What method of debriefing
i...
What educators are doing?**
• Applying phases1
• Ask learners to self-assess2
– e.g. Plus-Delta (+/Δ)
• Facilitating discu...
What makes the debriefing effective?
1. Supportive environment
2. Allows for trainee reactions / emotions
3. Specific, con...
PEARLS Framework
PEARLS – Blended Apprach Debriefing
Eppich, Cheng
What are the characteristics of these
methods, and when should they be
u...
Learner Self-Assessment
• Advantages
– Learner centered
– Easy to learn
– Multiple issues identified
quickly
What went wel...
Learner Self-Assessment
• Disadvantages
– Easy to get off track
– Can easily miss opportunity
to discuss rationale
– Educa...
Performance gap
Actual
performance
Desired
performance
Performance
gap
Rudolph et al 2008
Frames
Advocacy-Inquiry
• Promotes reflective
learning
• Allows for
understanding of
frames/rationale
• Group discussion
• Explor...
Directive Feedback
• Educators offers practical
solution(s) to performance
gaps
• Focused on actions
• Best for:
– Technic...
Directive Feedback
• Advantages
– Rapidly close performance
gaps
– Where rationale evident,
discussion not required
– Time...
Directive Feedback
• Disadvantages
– Assumed rationale may be
incorrect
– No exploration of rationale
– May be taken the w...
PEARLS Design process
Background
Framework Development
PEARLS Debriefing Tool
Usability Testing and
Feedback
PEARLS
Framework
Eppich, Cheng
ANALYSIS
Select method of Debriefing
How much time do you have?
ASK
Is the rationale evident?
Long Time
- Rationale
Short ...
Eppich, Cheng
PEARLS
Framework
Analysis
Were All Learning Objectives Covered? NO
RevisitLea
Performance Gaps
(+/∆ )
Close
Performance Gaps
Learner
Driven
Performa...
PEARLS Debriefing Script (Overview)
Eppich, Cheng 2015
'
Walter'Eppich,'MD,'MEd,'Adam'Cheng,'MD'
Table 6
Setting the scene...
Video Exercise 1
• Case:
– 12 month old baby
– Found at home unconscious, GCS 5
– RR 10 on arrival, Sat 92% RA, HR 50
– Pr...
Objectives
• Demonstrate
– Steps of rapid sequence intubation in a
trauma patient
– Adequate c-spine immobilization
• Clea...
Video Exercise 1
• Identify performance gaps
• Debriefing exercise
– Learner Self-Assessment
• Facilitator feedback
Video
Video Exercise 1 –
Learner Self-Assessment (Plus-Delta)
Identify Performance Gaps Close Performance Gaps
What aspects of t...
Video Exercise 2
Focused Facilitation
• Watch video
• Identify performance gaps
• Debriefing exercise
– Advocacy Inquiry
•...
Video
PEARLS Debriefing Script
PEARLS'Scripted'Debriefing'Tool'
'
Walter'Eppich,'MD,'MEd,'Adam'Cheng,'MD'
Table 7
Advocacy-inqui...
Video Exercise
Directive Feedback
Observed Performance Gap Close Performance Gap
I noticed…..
I observed….
I saw that….
I ...
Video Exercise 3
Putting it all together
• Watch Video
• Case
– 12 month old boy
– Fever, vomiting, unwell x 3 days
– Diag...
Video Exercise 3
Putting it all together
• Identify performance gaps
• Debriefing exercise
– Reactions phase
– Descriptive...
Video review
Video Exercise
Putting it all together
PEARLS'Scripted'Debriefing'Tool'
'
Walter'Eppich,'MD,'MEd,'Adam'Cheng,'MD'
Table 6
...
PEARLS
• Provides a framework for context-specific
application of commonly used approaches to
debriefing
• The PEARLS scri...
Acknowledgements
• Vincent Grant, Traci Robinson, Helen Catena, Wendy
Bissett, Kristin Fraser, Gord McNeil (KidSim Team)
•...
Questions?
Walter Eppich, MD, MEd
w-eppich@northwestern.edu
Adam Cheng, MD
chenger@me.com
Promoting Excellence And Reflective Learning in Simulation (PEARLS):
Promoting Excellence And Reflective Learning in Simulation (PEARLS):
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Promoting Excellence And Reflective Learning in Simulation (PEARLS):

In this presentation Dr. Eppich outlines the PEARLS Framework, a blended approach to healthcare debriefing that reconciles multiple approaches.

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Promoting Excellence And Reflective Learning in Simulation (PEARLS):

  1. 1. Promoting Excellence And Reflective Learning in Simulation (PEARLS): A Blended Approach to Healthcare Debriefing Walter Eppich1,2, Mark Adler1,2, Traci Robinson3, Wendy Bissett3, James Huffman4, Kristin Fraser4, Josh Ross5, Tobias Everett6,7, Jon Duff8, Adam Cheng3,4 1Northwestern University Feinberg School of Medicine, 2Ann & Robert H. Lurie Children’s Hospital of Chicago/USA 3KidSim Simulation Program, Alberta Children’s Hospital 4University of Calgary, Calgary/CA 5University of Wisconsin, Madison/USA 6Hospital for Sick Children, Toronto/CA 7University of Toronto, Toronto/CA 8Stollery Children’s Hospital, Edmonton/CA
  2. 2. Disclosure • Eppich – Center for Medical Simulation, Boston/USA – Honoraria to teach on train-the-trainer courses with PAEDSIM e.V. • Cheng – Simulation Educator with Royal College of Physicians and Surgeons of Canada – SSH Board of Directors • Others – No disclosures
  3. 3. Welcome & Introductions
  4. 4. Our basic assumption • Everyone participating in training is intelligent, capable, does their best, and wants to improve Center for Medical Simulation
  5. 5. Ground rules
  6. 6. Learning objectives After this session, you will be better able to: 1. Identify three different educational strategies used during debriefing and when to use them 2. Discuss how learner self-assessment focused facilitation strategies and directive feedback and teaching fit within the PEARLS debriefing framework 3. Apply the PEARLS blended approach to debriefing using the decision support aid and the PEARLS debriefing tool
  7. 7. Workshop Outline • Introductions • PEARLS overview • Video exercises – Self-assessment (e.g. Plus-Delta) – Focused facilitation (e.g. Advocacy-Inquiry) – Directive Feedback – Putting it all together • Take Home Messages
  8. 8. Debriefing • Facilitated reflection in experiential learning1 • Involves “the active participation of learners, guided by a facilitator or instructor whose primary goal is to identify and close gaps in knowledge and skills.”2 1Fanning and Gaba 2007 2Raemer et al. 2011
  9. 9. Debriefing • Feedback and debriefing an essential component of simulation-based education1,2 • What method of debriefing is best? – No head to head studies3 – No current method is ideal 1Issenberg et al. 2005 2McGaghie et al. 2010 3Raemer et al. 2011
  10. 10. What educators are doing?** • Applying phases1 • Ask learners to self-assess2 – e.g. Plus-Delta (+/Δ) • Facilitating discussion – e.g. Advocacy-Inquiry3,4,5 • Provide directive feedback and teaching6 **Krogh, K, AMEE 2013 1Steinwachs 1992 2Fanning & Gaba 2007 2Sargeant et al. 2010, 2011, 2012 3,4,5Rudolph et al. 2006, 2007, 2008 6Archer 2010
  11. 11. What makes the debriefing effective? 1. Supportive environment 2. Allows for trainee reactions / emotions 3. Specific, concrete observation 4. Honest but non-threatening approach 5. Trainees shares their perspectives on events 6. Focus on improvement or sustaining excellence Simon et al. 2010. Cantillon & Sargent 2008 Archer 2010, Mann et al. 2011, Eva et al. 2012, Brett-Fleegler et al. 2012, Ahmed et al. 2012, Arora et al 2012, etc
  12. 12. PEARLS Framework
  13. 13. PEARLS – Blended Apprach Debriefing Eppich, Cheng What are the characteristics of these methods, and when should they be used?
  14. 14. Learner Self-Assessment • Advantages – Learner centered – Easy to learn – Multiple issues identified quickly What went well (plus) What could be changed (delta) AND WHY? What was easy? Challenging?
  15. 15. Learner Self-Assessment • Disadvantages – Easy to get off track – Can easily miss opportunity to discuss rationale – Educator must tactfully close performance gaps
  16. 16. Performance gap Actual performance Desired performance Performance gap Rudolph et al 2008 Frames
  17. 17. Advocacy-Inquiry • Promotes reflective learning • Allows for understanding of frames/rationale • Group discussion • Exploration of team dynamics Disadvantages • Can be time consuming • Very difficult to master • Risk of conversation going off-topic Advantages
  18. 18. Directive Feedback • Educators offers practical solution(s) to performance gaps • Focused on actions • Best for: – Technical skills – Knowledge gaps
  19. 19. Directive Feedback • Advantages – Rapidly close performance gaps – Where rationale evident, discussion not required – Time efficient
  20. 20. Directive Feedback • Disadvantages – Assumed rationale may be incorrect – No exploration of rationale – May be taken the wrong way if not delivered effectively – Teacher centered – Limits group discussion
  21. 21. PEARLS Design process Background Framework Development PEARLS Debriefing Tool Usability Testing and Feedback
  22. 22. PEARLS Framework Eppich, Cheng
  23. 23. ANALYSIS Select method of Debriefing How much time do you have? ASK Is the rationale evident? Long Time - Rationale Short Time + Rationale Short Time + / - Rationale DESCRIPTIVE May shorten if students appear to have a shared understanding of case Descriptive Phase REACTIONS Reactions Phase PEARLS Framework Eppich, Cheng
  24. 24. Eppich, Cheng PEARLS Framework Analysis
  25. 25. Were All Learning Objectives Covered? NO RevisitLea Performance Gaps (+/∆ ) Close Performance Gaps Learner Driven Performance Gaps Instructor Driven Close Performance Gaps Learner Driven Instructor Driven Close Performance Gaps Instructor Driven SUMMARY Application / Summary Learner Driven Instructor Driven YES PEARLS Framework Eppich, Cheng
  26. 26. PEARLS Debriefing Script (Overview) Eppich, Cheng 2015 ' Walter'Eppich,'MD,'MEd,'Adam'Cheng,'MD' Table 6 Setting the scene (may also occur before the first scenario debriefing, may abbreviate or omit for subsequent debriefings): “I’ll spend aboutt XX minutes debriefing the case with you. First,I’ll be interested to hear how you felt during the scenario, second I’d like someone to describe what the case was about to make sure we are all on the same page. Then we’ll to explore the aspects of the case you managed effectively and those aspects you would have manage differently. I’ll be keen to hear what was going through your mind at various points in the case. We’ll end by summarizing some take home points and identifying strategies to apply them in your work.” PEARLS Debriefing Framework REACTION · “How did that feel?” Potential follow-up questions: · “How was that for the rest of you?”, “What were the rest of you feeling at the time?” DESCRIPTION · “Can someone summarize what the case was about from a medical point of view? What were the main issues you had to deal with?” Potential follow up questions: · “What happened next?”, “What things did you do for the patient?” ANALYSIS Signal the transition to the analysis of the case and frame the discussion: · “Now that we are clear about what happened, let’s talk more about that case. There were aspects I think you managed effectively and other areas that you might want to have done differently. I would like to explore each area with you.” Learner Self-Assessment (e.g. Plus-Delta) “What aspects of the case do you think you managed well?” “What aspects of the case would want to change?” Directive feedback and teaching Provide the relevant knowledge or tips to perform the action correctly · I noticed you [insert performance gap here]. Next time, you may want to … [close gap]…because [provide rationale] Facilitation (e.g. Advocacy-Inquiry) · Specifically state what you would like to talk about (“I would like to spend a few minutes talking about XXX”) Elicit underlying rationale for actions: see page 2 for approach Are there any outstanding issues we haven’t discussed yet before we start to close? APPLICATION/SUMMARIZING · Learner Driven: “I like to close the debriefing by having each you state one two take-aways that will help you in the future”. · Instructor Driven: “In summary, the key learning points from this case were: …….”
  27. 27. Video Exercise 1 • Case: – 12 month old baby – Found at home unconscious, GCS 5 – RR 10 on arrival, Sat 92% RA, HR 50 – Presumptive diagnosis: • Severe head injury, increased ICP
  28. 28. Objectives • Demonstrate – Steps of rapid sequence intubation in a trauma patient – Adequate c-spine immobilization • Clear communication and teamwork surrounding airway management management Walter Eppich, MD, MEd
  29. 29. Video Exercise 1 • Identify performance gaps • Debriefing exercise – Learner Self-Assessment • Facilitator feedback
  30. 30. Video
  31. 31. Video Exercise 1 – Learner Self-Assessment (Plus-Delta) Identify Performance Gaps Close Performance Gaps What aspects of the case do you think you managed well? What aspects of the case management would you want to change AND WHY? Close gaps through teaching and discussion - Instructor prompted - Learner driven
  32. 32. Video Exercise 2 Focused Facilitation • Watch video • Identify performance gaps • Debriefing exercise – Advocacy Inquiry • Facilitator feedback
  33. 33. Video
  34. 34. PEARLS Debriefing Script PEARLS'Scripted'Debriefing'Tool' ' Walter'Eppich,'MD,'MEd,'Adam'Cheng,'MD' Table 7 Advocacy-inquiry: pairing your point of view with a question to get trainees’ perspective ADVOCACY - INQUIRY STEP 1: EXPLORE PERFORMANCE GAPS Observation about a performance gap Express your point of view about the observed performance gap Ask about the perspective · I noticed that… · I saw that… I heard you say… Appreciation · I liked that…. · I thought that was interesting / fascinating… Appreciation or concern · I was thinking… · That makes me think that… · I had the impression that… · It seemed to me that… Concern · I was wishing that · I felt uncomfortable because… · I was worried/concerned… · How do you see it? · I wonder what your thoughts were at the time? · What was going through your mind? · How did you assess the situation? · What were your priorities at the time? · How did the team get organized? · How did you decided that…. STEP 2: UNDERSTAND RATIONALE AND CLOSE PERFORMANCE GAPS Clarify understanding of the trainee’s rationale for action Explore the rationale and close the performance gap Help learners generalize · So what I’m hearing is that [insert performance gap] was related to [insert frame here]…. · If I understand correctly, you are saying that [insert performance gap] was due to [insert frame here] Positive Performance Gap · Identify and reinforce existing frame through discussion · Discuss/teach to highlight positive performance Negative Performance Gap · Identify and explore new frame through discussion · Teach to close performance gap when learning need is clear · What strategies do you see going forward that would he helpful here? · How will this impact your performance next time? · How would you manage that situation differently next time? · How will your train of thought change the next time you encounter a similar situation? Eppich, Cheng 2012
  35. 35. Video Exercise Directive Feedback Observed Performance Gap Close Performance Gap I noticed….. I observed…. I saw that…. I heard you say… Next time, you may want to…. because….. An alternative way to do this….because…. What I do to to prevent the patient from [insert result here], is…. because ….. My take on the guidelines is… because…..
  36. 36. Video Exercise 3 Putting it all together • Watch Video • Case – 12 month old boy – Fever, vomiting, unwell x 3 days – Diagnosis: Myocarditis
  37. 37. Video Exercise 3 Putting it all together • Identify performance gaps • Debriefing exercise – Reactions phase – Descriptive phase – Analysis (1 or 2 performance gaps) • Facilitator feedback
  38. 38. Video review
  39. 39. Video Exercise Putting it all together PEARLS'Scripted'Debriefing'Tool' ' Walter'Eppich,'MD,'MEd,'Adam'Cheng,'MD' Table 6 Setting the scene (may also occur before the first scenario debriefing, may abbreviate or omit for subsequent debriefings): “I’ll spend aboutt XX minutes debriefing the case with you. First,I’ll be interested to hear how you felt during the scenario, second I’d like someone to describe what the case was about to make sure we are all on the same page. Then we’ll to explore the aspects of the case you managed effectively and those aspects you would have manage differently. I’ll be keen to hear what was going through your mind at various points in the case. We’ll end by summarizing some take home points and identifying strategies to apply them in your work.” PEARLS Debriefing Framework REACTION · “How did that feel?” Potential follow-up questions: · “How was that for the rest of you?”, “What were the rest of you feeling at the time?” DESCRIPTION · “Can someone summarize what the case was about from a medical point of view? What were the main issues you had to deal with?” Potential follow up questions: · “What happened next?”, “What things did you do for the patient?” ANALYSIS Signal the transition to the analysis of the case and frame the discussion: · “Now that we are clear about what happened, let’s talk more about that case. There were aspects I think you managed effectively and other areas that you might want to have done differently. I would like to explore each area with you.” Learner Self-Assessment (e.g. Plus-Delta) “What aspects of the case do you think you managed well?” “What aspects of the case would want to change?” Directive feedback and teaching Provide the relevant knowledge or tips to perform the action correctly · I noticed you [insert performance gap here]. Next time, you may want to … [close gap]…because [provide rationale] Facilitation (e.g. Advocacy-Inquiry) · Specifically state what you would like to talk about (“I would like to spend a few minutes talking about XXX”) Elicit underlying rationale for actions: see page 2 for approach Are there any outstanding issues we haven’t discussed yet before we start to close? APPLICATION/SUMMARIZING · Learner Driven: “I like to close the debriefing by having each you state one two take-aways that will help you in the future”. · Instructor Driven: “In summary, the key learning points from this case were: …….”
  40. 40. PEARLS • Provides a framework for context-specific application of commonly used approaches to debriefing • The PEARLS scripted debriefing tool can serve as an adjunct in faculty development initiatives • Future work will determine the extent to which PEARLS promotes various aspects of debriefing expertise
  41. 41. Acknowledgements • Vincent Grant, Traci Robinson, Helen Catena, Wendy Bissett, Kristin Fraser, Gord McNeil (KidSim Team) • Nicola Robertson (PEARLS flow diagram) • Mark Adler (Northwestern University) • Jenny Rudolph (Center for Medical Simulation) • EXPRESS Collaborative • Royal College of Physicians and Surgeons of Canada (SET team) and Robert Simon
  42. 42. Questions? Walter Eppich, MD, MEd w-eppich@northwestern.edu Adam Cheng, MD chenger@me.com

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