Utilization of micro-debriefing in medical student simulation: An emergency department experience

Introduction

Medical simulation has been incorporated as an essential strategy into the medical school curriculum for teaching of knowledge, procedural skills, teamwork, communication and even crisis resource management in the past several decades. There are various steps in conducting an effective simulation based on best practices: defined goals and objectives, sufficient pre-brief, established case scenarios, and adequate debriefing. ¹ The most important component of simulation-based learning is debriefing; this is the opportunity through which participants have to reflect intentionally on events that have happened, gain an understanding of their actions during distinct emotional states and thoughts processes, and modify their behaviours as a result.^2,3 Debriefing strategies are based on learner types, scenario objectives, and the preference of the educator leading the debrief. Irrespective of techniques, debriefing leads to meaningful learning opportunities via experiential reflection, feedbacks and interactive exchanges which integrate into later action.^4–14 Reflective practice outlines how it is not the experience alone but the deliberate reflection on experience and contextual frame of reference that leads to active learning.^3,4 When appropriately incorporated into clinical training, educationally productive debriefing following medical simulation can inevitably improve patient outcomes. ³ The debriefing may occur at the end of the simulation (traditional post-event debrief) or periodic stopping points during a simulation (micro-debrief; rapid cycle deliberate practice) for real-time coaching. ² Ample framework of debriefings have been proposed and practiced with varying degrees of subjective successes as no one optimal way has been recommended. ³ Micro-debriefing which is also termed “in-simulation debriefing”, “concurrent debriefing” and “within-event debriefing” ⁶ enables the delivery of bitesize chunks to novice participants such as medical students to maximize learning without cognitive overload while at the same time, allowing the facilitator to guide them through the scenario in order to maximize learning throughput. Students may then proceed on to play out the scenarios based on real-time reviews of their performance. It provides a safe, familiarizing and highly-focused bidirectional open communication channel for facilitators or educators as simulation-based education modalities might appear daunting especially for novice learners. Using this method, the facilitator can adjourn the session any time an error or doubt occurs and uses a “pause-(rewind)-proceed again” approach to allow the learners to repeat specific technical skills or cognitive tasks after simplified guided feedback has been provided. ⁶ This technique is best applied when the underlying rationale for the performance gap is evident and when the learners have deficient clinical and simulation experience. ⁶ In comparison to rapid cycle deliberate practice which might potentially be labour/time-intensive due to cycling till mastery achievement ¹⁵ , micro-debriefing is a subtype of reflection-on-action technique with its efficacy yet to be examined in the emergency medicine setting. The purpose of this study is to evaluate its efficacy simplistically in the context of medical student simulation with respect to their perception on knowledge and skills translation.

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This preliminary mixed-method study was conducted at Singapore General Hospital which is affiliated with SingHealth Duke-NUS Institute of Medical Simulation (SIMS), from October 2021 to December 2022. Year-4 undergraduate medical students were required to participate in one high-fidelity (SimMan 3G) simulation-based scenario training during their 3-week posting at the simulation laboratory. The pre-planned scenarios included: a gentleman with acute anterior myocardial infarction that degenerated into a ventricular fibrillation cardiopulmonary collapse; a lady with asthma exacerbation and concomitant community-acquired pneumonia; a gentleman with traumatic open-book pelvic fracture complicated by haemorrhagic shock and an lady with a background of end-stage kidney disease on haemodialysis presenting with acute pulmonary edema and hyperkalemia. The students were grouped into teams of 2 to 3 with self-assignment of roles. During the approximately two-hour session, the senior simulation faculty would conduct pre-briefing which included mannequin orientation, learning objectives, ground rules and expectations. Following this the same senior simulation faculty who is proficient in micro-debrief facilitated all the sessions whereby medical students interacted with the mannequin demonstrating appropriate assessment, interventions, and crisis resource management principles. Throughout the scenarios, the faculty who were inside the laboratory would pause at different junctures to reinforce or rectify certain targeted educational outputs/values or desired actions per particular algorithms in order to prompt the students on specific learning objectives as outlined whenever errors or uncertainties arose. One simulation technician would be situated hidden behind a one-way mirror, supplying voice-overs and operating the wireless monitors that displayed dynamic vitals and necessary investigations. After the session, the faculty would summarize with any final clarifications regarding the scenarios. An anonymous Debriefing Assessment for Simulation in Healthcare (DASH student version)^9,14 was used by students to rate their facilitators on six unweighted, criterion-referenced elements from 1 being extremely ineffective/detrimental to 7 being extremely effective/outstanding, ¹⁴ and free-text responses were also collated electronically via FormSG^TM.

There was a 100% response rate for the DASH element survey. The results of the DASH survey are presented in Table 1. On a 7-point scale, the students found micro-debriefing to be extremely effective in setting the stage for an engaging experience 6.92 [6.85–6.89] and maintaining an engaging context for learning 6.92 [6.85–6.89]. They also found it to be highly structured 6.90 [6.83–6.97]. Micro-debriefing appears to also facilitate in-depth discussion to promote self-reflection 6.87 [6.78–6.95], aiding students in identifying what they did well and what they did poorly 6.86 [6.77–6.95], and showing them how they can improve and sustain their performance 6.89 [6.80–6.97].

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Table 1.

Descriptive statistics of DASH elements.

Variables	Mean ± SD	N = 6195% confidence interval
The instructor set the stage for an engaging learning experience	6.92 ± 0.28	6.85–6.89
The instructor maintained an engaging context for learning	6.92 ± 0.28	6.85–6.89
The instructor structured the debriefing in an organized way	6.90 ± 0.29	6.83–6.97
The instructor provoked in-depth discussions that led me to reflect on my performance	6.87 ± 0.33	6.78–6.95
The instructor identified what I did well or poorly -and why	6.86 ± 0.34	6.77–6.95
The instructor helped me see how to improve or how to sustain good performance	6.89 ± 0.32	6.80–6.97

A total of 95 free-text responses were collected and analysed. The distribution of the responses across all six questions is represented in Table 2. Independent Observer A’s and Observer B’s thematic analyses of the students’ response free text responses are collated in Tables 3 and 4 respectively. When asked, “What was the most valuable portion of today’s simulation and debriefing experience? Why was it valuable?”, both observers noted that the opportunity to practice and apply clinical knowledge was ranked amongst the highest in response. Furthermore, it is noted that medical students appreciated the guided nature of cases (“Cases were guided,” Observer A N = 5; “Guidance of tutor” Observer B, N = 6), and reported a good learning experience (Observer A n = 1, Observer B n = 4). Other themes identified included “Creation of safe space” n = 3 by Observer A, and “Pacing of simulation session” by Observer B possibly alluding to participants feeling psychologically safe and the cases progression was at a comfortable pace.

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Table 2.

Total Number of Collated Free-text responses.

Question	Total response collected
1. What was the most valuable portion of today’s simulation and debriefing experience? Why was it valuable?	37
2. What was the least valuable portion of your simulation and debriefing experience today? Why was it least valuable?	7
3. What recommendation would you make to improve the simulation and debriefing learning experience?	5
4. What is the first thing that comes to mind about the simulation experience?	17
5. What do you think went well during the simulation experience and why?	15
6. What would you do differently and why?	14

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Table 3.

Thematic analysis by Observer A.

Question	Themes	Count
1. What was the most valuable portion of today’s simulation and debriefing experience? Why was it valuable?	Cases were relevant	5
	Practical experience in clinical approaches	24
	Cases were guided	5
	Creation of a safe space for participation	3
	The environment is conducive for active participation	1
	Good learning experience	1
	Debriefing	2
2. What was the least valuable portion of your simulation and debriefing experience today? Why was it least valuable?	Lack of opportunity	2
	Lack of scenarios	2
	Timing of simulation activity - better at the start of clinical posting	2
	Need for suspension of disbelief	2
3. What recommendation would you make to improve the simulation and debriefing learning experience?	Pre-readings	3
	More scenarios	1
	Post simulation notes	1
4. What is the first thing that comes to mind about the simulation experience?	Fun and enjoyable	6
	Useful and or valuable	4
	Practical and or relevant	5
	Guided	1
	Engaging	3
5. What do you think went well during the simulation experience and why?	Good case progression and flow	1
	Realistic	3
	Good case variety	1
	Good guidance	1
	Creation of a safe space	2
	Good opportunity to participate	2
	Case debriefing and discussion	2
	Practical learning	2
	Others	2
6. What would you do differently and why?	Prepare for the session	8
	Refine their clinical approach	5
	Have more case scenarios	2

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Table 4.

Thematic analysis by Observer B.

Question	Themes	Count
1. What was the most valuable portion of today’s simulation and debriefing experience? Why was it valuable?	Hands-on experience	7
	Relevant scenarios	6
	Guidance of tutor	6
	Application of knowledge in day-to-day work	10
	Immediate real-time feedback and knowledge application	4
	Improve knowledge	5
	Opportunity to practice	12
	Improve confidence	1
	Overall learning experience	4
	The pacing of simulation session	2
2. What was the least valuable portion of your simulation and debriefing experience today? Why was it least valuable?	Lack of scenarios	3
	Simulation to be scheduled earlier in posting	2
	New knowledge learnt – changed perspectives	2
3. What recommendation would you make to improve the simulation and debriefing learning experience?	Pre-readings	3
	Post simulation notes	1
	More clinical scenarios	1
4. What is the first thing that comes to mind about the simulation experience?	Useful	4
	Fun and enjoyable	8
	Good practice	2
	Relevance	5
	Hands-on experience	1
	Skill – putting on C-collar	1
5. What do you think went well during the simulation experience and why?	Opportunity to practice/ participate	4
	Effective communication	1
	Learning and improved knowledge	6
	Great variety of scenario	6
	Tutor’s guidance	8
	Relevant to daily practice	5
	Generally good	2
	Good flow and sequence of session	2
	Debriefing after each scenario	1
	Fun and enjoyable	1
6. What would you do differently and why?	Prepare for the session	4
	More clinical scenarios	1
	Familiarise with approaches to trauma patients	5

In the follow-up question “What was the least valuable portion of your simulation and debriefing experience today? Why was it least valuable?”, most of the responses can be attributed to the inherent nature of simulation “Lack of opportunities”, “lack of scenarios”, “the need for suspension of disbelief”. Interestingly some students would prefer to have the simulation activities at an earlier stage of their clinical posting.

When asked “What recommendation would you make to improve the simulation and debriefing learning experience?”, students generally preferred to have more pre-readings and post-simulation notes. This possibly alludes to the discovery of their own knowledge gaps during the simulation activity.

In answering “What is the first thing that comes to mind about the simulation experience?”, we note that students generally find it useful and relevant to their training while having a fun and enjoyable experience.

As for answering “What do you think went well during the simulation experience and why?”, the common themes include having realistic scenarios, opportunities to participate, practical learning, good guidance, a safe environment, and good case debriefing and discussion.

Conclusion

Micro-debrief is not only time-efficient but it allows for just-in-time learning especially for novice learners who lack simulation knowledge as well as inadequate medical foundation on acute clinical presentations. This in theory allows scaffolding of the learning experience and helps progress the simulation scenario to achieve deliberate learning. For micro-debriefing, the general core principles still apply such as debriefing with good judgement, etc. and appropriate purposeful pauses to prevent any disruption to cognitive flow: providing bitesize information which are relevant and targeted. The interaction during these pauses should also be bi-directional between the learners and facilitators, as well as timely and focused in order to clarify any misconceptions of clinical reasoning instantaneously. Students valued micro-debriefing as good guidance from the facilitator during stops, practical application of clinical knowledge, and was able to achieve desired outcomes as per all simulation activities. They also felt psychologically safe to perform during the scenario while maintaining realism undefined and were comfortable with the pace and flow of the scenarios. Therefore micro-debriefing as part of simulation-based education does provide an effective alternative to reinforce positive learning experience and strengthen clinical reasoning skills especially for novice learners.