D Guided Reflectionfornewfaculty

Taking Learning to the Next Level

Beatrice Kastenbaum, RN, MSN, CNE

Guided Reflection for New Faculty

© 2008 B. Kastenbaum RN, MSN, CNE

What is Guided Reflection?

The active learner processes the simulated learning experience through rigorous self-reflection by examining the underlying values, assumptions and knowledge-bases that informs professional practice

Reflection is enhanced by the presence of the teacher/expert/mentor.


Who participates in Guided Reflection?

• Students: curious to learn, active, open, engaged, self-monitoring, self-aware, self-confident

• Faculty: knowledgeable, competent, role modeling the profession, active, engaged, self-monitoring, self-aware, self confident, open, warm, encouraging

• Simulation staff: supportive, comfortable with the equipment, the process

• Visitors: respectful of student learning© 2008 B. Kastenbaum RN, MSN,

CNE

Sim from the Student’s Point of View

• Get prepared before coming• Get started—orient to simulation environment,

get report

•“Oh No! It is my turn.”• Assess the patient, wait for something to

happen, diagnose the problem• PLAN (make a clinical decision)• Implement interventions• Get help if necessary• Evaluate and document care, APPLAUSE!• Whew!!!


When does Guided Reflection Occur?

• Immediately after the simulation

• After a break

• Later, in clinical conference

• Later, on a discussion board

• Later, answering quiz questions

• Later, answering a survey

• Later, in a journal entry


Where does Guided Reflection Occur?

• Simulation room itself

• Viewing room

• Clinical conference

• Faculty office

• On-line


Why do Guided Reflection?

• Examine learning that occurred during the scenario in relation to the objectives

• Resolve confusion and misconceptions resulting from the scenario

• Examine values, assumptions, and knowledge that drive clinical decisions.

• Focus on students’ mental models, actions and results in a safe place to consolidate learning and promote change in practice.


Who should lead Guided Reflection?

A. Students

B. Faculty

C. Staff

D. Visitors

The answer is: A. Students with help as needed from faculty.


A word about collaborative learning• Gain student consent and thoughts about

rules related to simulation and reflection.

• Do this before simulation starts (These rules might also guide clinical conference time.)

• Topics might include: – preparation,– group leadership, – how to offer feedback


Instructor’s Point of View• Get prepared before coming— Debriefing

is scary!

• Approach with curiosity—What will the instructor learn today?

• Get help when needed

• Give feedback to other faculty and staff about the simulation experience.


Possible approaches– Judgmental—sage on the stage – Non-judgmental

• Use Socratic questioning• Develop based on objectives, • May not directly address what happened or

mistakes

– Advocacy with Inquiry • Share instructor’s viewpoint to initiate dialogue• Focus on objectives• Focus on all learners including teacher• Seek to make meaning of the situation

See handout: Rudolph et. al. “There is no such thing as non-judgmental debriefing” © 2008 B. Kastenbaum RN, MSN,

CNE

What is a good starting place?Thank the students for their participation.

Uncover assumptions about the situation– How did it go?– What did you think was happening?

Example: “I noticed you decided to call for help when _________ happened. I might have called for help when _____ happened or waited until I had ______ information.

Can you tell us what guided your decision?”


Inquiring• Story meaning to student meaning

for future. – Tell us what happened – What did it mean when it happened?– How will you use this in the future?

• Plus/Delta— Write on board for visual folks.

– What went well? – What did not go well?

Be ready to wait after asking a question


Modeling feedbackUse observation guides such as a competency scale

Guide feedback that – is specific, and credible, based on a standard, – focuses on actions and effort, – identifies changes possible, – recognizes individual challenges,– does not distract from the objectives, – starts and ends positively

Share your own perceptions and judgments sparingly


Think about learning styles

• Visual learners—use the board to make charts, review lab values, make a concept map.

• Auditory folks—listen for “Ah Hahs!,” have the students say what they are realizing. Listen again for a sound that is a cue in the scenario.

• When you see the light go on for a student, ask about it.


Use the wisdom of the groupEncourage discussion of alternatives

“What other ways could Susan have included the family?”

Guide group to search for answers—send to resources rather than “giving” answers“Good question. I am not sure I know the answer, let’s

see what (name a resource or search strategy) will tell us?”

Encourage each member to participate“George, I wonder what you would do if _____?”


Interruption/Redirection

Use when negative vibes are occurring,“Let’s go back to ___”

“What did you notice when ____”

Use when topic is finished. “Okay, moving on. What was happening when _____?”

This is not impolite but expected of a facilitator.


Summarize• Address misconceptions, inappropriate

actions, missed assessment or interventions if not done earlier by the group.

• Ask how the group will use what they have experienced in real situations.

• Not too short and not too long--“Too much is too much”


Decisions

• To watch the video or not?

• Should the students repeat the scenario?

Ask yourself: What are the objectives and how will this enhance the students’ learning?


Review: What is happening during Guided Reflection?

• Debriefing• Reflecting• Thinking critically• Checking assumptions• Looking for alternatives• Defending—not usually a word associated with

this list. Has two connotations—defending ideas in a good way that enlightens listeners, and being defensive.


Disruptions to Reflection

• Student states:– Manikin is not real, or confused about what is real or

not– Situation would never happen this way because…– Needed equipment did not work or was unavailable– Others were watching

• Students lack preparation and knowledge• Group acts bored or all knowing • Group dynamics interfere with trust needed for

collaborative learning.© 2008 B. Kastenbaum RN, MSN,

CNE

What now??

Is it defensiveness, preserving social “face”?

• Work to maintain trust and psychological safety for the students.

• This does not mean that instructors relinquish their expertise, or “sugar-coat” their judgments; rather, they state their view of the situation and use that as a springboard to legitimize and explore the trainees’ view.


It is not self-preservation, now what?

• Hear it and go past it.

• Reinforce the need to prepare for simulation as if preparing for a patient in clinical practice.

• Be sure to let the sim staff know if there may need to be changes to the set up or the way the scenario is being run.


What about those who do not meet objectives?

• What were the objectives—formative or summative?

• Deal with individual behavior or knowledge deficits individually.

• Have high expectations, expect preparation, good effort and collaboration.

• Deal with group personality problems separately.


What detracts from learning in the Simulation Session?

• Lack of initial explanation of purpose, objectives, characteristics and use of the manikin

• Lack of preparation by participants or faculty

• Lack of engagement by any members of the group

• Underestimating participant emotions


More bad habits

• Closed question, excessive criticism or negativism, caustic language

• Mocking or humiliating team members by any member of the group

• Autocratic attitude of the teacher

• Excessive instructor discussion, too little student participation

• Highlighting too many key teaching points


You wouldn’t do this…

• Allow discussion to focus on the limitations of simulation

• Consume excessive time

• Omit the summary at the end of guided reflection to reinforce learning of best practices and eliminate misconceptions about correct actions


Evaluation of Participation

Formative or Summative ? • Check lists—each element is assessed individually—

Straight catheter insertion• Global rubric—elements are categorized and judged

as by grouping—Competency Scale• Achievement of outcomes—quality is an all-or-none

property supported by evidence based elements that are linked to the end point.—Did the patient get competent care in the end?

Nolan, T and Berwick, D. (2006) All-or-None Measurement Raises the Bar on Performance. JAMA 1168-1170.


Ways for Participants to evaluate learning:

Self-evaluation View video togetherQuizzes or other written assessment of knowledgeRepeat simulationClinical observations Student surveys/satisfaction –On Bb for each

courseAnecdotal reports (I did this in sim and then …)Compare expert (EBP) to actual performanceRCT’s


合知一行

Knowledge is the beginning of practice;

Action is the completion of knowing.

Adapted from The Philosophy of Wang Yang-ming, (1916) translated by Frederick Goodrich Henke. Open Court Publishing Co. New York


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