The postclinical conference is regarded as a way to link theory with practice, enabling a small group of students to discuss and reflect on what transpired throughout the day in the clinical setting. Vezeau has noted, however, that although a significant portion of clinical hours is dedicated to clinical conference time, the literature contains little evidence and discussion about the typical patterns of and methods used during these conferences.1 Moreover, instructors—who may be adjuncts, graduate students, or work part time—often don't have the same skill set or specialty level and tend to draw from their own experiences rather than use proven pedagogical approaches to clinical teaching. These variables can lead to inconsistent learning in the postclinical conference.2
Harvey has described how linking theory to practice using guided questions helped to facilitate effective postclinical conferences among students enrolled in a baccalaureate nursing program.2 Yet, a study conducted by Hsu of postclinical conference teaching found that nursing faculty members mostly asked students lower-level questions (those related to knowledge and comprehension) instead of higher-order questions (those that promote the development of critical thinking) during postclinical conferences.3
Debriefing is an educational method that can be used to maximize learning, promote reflective thinking, and provide learners with feedback that helps them to improve future performance.4 Although it's primarily used during simulation-based nursing education, it also holds great potential for use during postclinical conferences. In this article, we examine various debriefing methods and describe scenarios in which clinical instructors can utilize this approach to improve the effectiveness of the postclinical conference.
DEBRIEFING—NOT JUST FOR SIMULATION
Debriefing has played a pivotal role in student learning since nursing faculty began incorporating simulation into their educational programs. It is a formative assessment in which students discuss what transpired in the simulation and the instructor provides tailored feedback.5 This feedback allows students to discuss what went well during a simulation experience and what could have been done differently. This time for reflection and discussion promotes student learning. The key component of successful debriefing is enabling students to understand and integrate their experiences into their practice, so they can better promote and administer safe care to their patients.6
Debriefing is considered to be one of the most important aspects of simulation-based learning.7 In fact, Shinnick and colleagues found that students gained more knowledge after the debriefing phase of simulation than during the hands-on component.8 Boet and colleagues conducted a study in which students critiqued their own performance after simulation compared with an instructor-led debriefing, and both approaches were found to be effective.9 Ryoo and Ha's study further supports these findings, demonstrating competency among students who received immediate feedback using standardized debriefing methods.10
Little research has examined the use of debriefing in other areas of the curriculum. Bavier has expressed concern that the technique has been linked so closely with simulation that nurse educators have overlooked its use in other settings, where it can be used to cultivate critical thinking skills.11 In 2015, a report from the National League for Nursing (NLN) stated that the NLN and the International Nursing Association for Clinical Simulation and Learning (INACSL) believed that nursing education could be transformed if debriefing were no longer relegated to simulation alone but was instead integrated across the curriculum.12
During postclinical conferences, instructors can follow the INACSL's debriefing standards, which were developed for faculty conducting simulation.6 Following these best practice standards can help to prevent mistakes and patterns of poor practice by the learner. The standards also offer specific objectives for instructors. These include ensuring that debriefing occurs in an environment that promotes trust and is conducive to learning, allowing for clear communication analysis and reflection, and providing constructive feedback.6 A few of the methods used by educators to help facilitate successful debriefing include “debriefing for meaningful learning,”13 “debriefing with good judgment,”14 and “promoting excellence and reflective learning in simulation (PEARLS).”15
Debriefing for meaningful learning. According to Dreifuerst, this method “begins with a systematic process to release emotions from the simulation experience and moves into a critical analysis of the events.”13 This process features the use of six components: (1) engaging participants, (2) exploring or reflecting on the experience, (3) explaining (decisions and actions, for instance), (4) elaborating or expanding the analysis, (5) evaluating the experience, and (6) extending inferential or analytical thinking.13 Following a clinical experience, students are brought together to reexamine the experience. During that time, they are encouraged to express any emotions, which helps them to frame the experience, thereby embedding it in their memory. Feedback regarding cognitive, affective, and psychomotor skills is delivered in a positive manner to promote student learning. All students are encouraged to provide input. The clinical instructor frames the experience in a way that enables the students to transfer their knowledge to future experiences.13
Debriefing with good judgment is a model that focuses on sharing the expert opinions of the instructor and critical feedback while simultaneously safeguarding the feelings of learners.14 Mistakes or a misdirection by students can be used as opportunities to learn how to prevent future clinical errors. The debriefing with good judgment model comprises three distinct elements, the first of which is a conceptual model that posits that a student's “frame” (that is, a student's knowledge, assumptions, and feelings) shapes her or his actions.14 The second element involves the instructor investigating students’ mistakes rather than simply viewing them as errors. The third element is a conversational technique that combines advocacy with inquiry. Rudolph and colleagues describe how instructors use advocacy, a type of speech, to objectively observe a student's actions while subjectively judging the actions. Inquiry statements allow the learner to reflect on these actions, correct errors, and, optimally, improve performance.14 The aim of this model is to allow the learner to discuss any errors and reflect on them in a safe environment.
PEARLS, which utilizes a blend of strategies, is the debriefing framework used at our school of nursing. The PEARLS script allows instructors to use open-ended questions and has four phases: reaction, description, analysis, and application/summary.15 In the reaction phase, a student might be asked, “How are you feeling?” after conducting a simulation. The other students may also be asked to describe their feelings. This type of questioning allows students to reflect on what they've experienced. The descriptive phase allows participants to summarize events, whereas the analysis phase is a time of learner self-assessment. During this phase, students ask themselves, “What did I learn?” or “What aspects would I change?” The summary phase, which may be instructor or learner led, is a time for the learner to reflect on any take-home messages or lessons learned during a clinical experience.15 For an example of how this method can be used, see Following the PEARLS Script.
Using a scripted debriefing framework such as PEARLS allows the instructor to ask questions and probe a situation deeper. The goal is for the instructor to listen and guide the students rather than problem solve or lecture, which novice instructors may have a tendency to do.15 Clinical instructors also need to foster positive feedback. At times, they may find it difficult to lead debriefing, because they are worried about their feedback damaging their relationships with the students.14
In our nursing school, we've also witnessed instructors use ineffective debriefing methods. In one instance, an instructor scolded a student in the postclinical conference, asking, “How stupid were you to want to give your patient a medication when the allergy was clearly noted in his chart?” Another time, after a mock code in the simulation lab, an instructor told a group of students they had acted like they had no idea the patient might die. Such approaches shame the learner. As Rudolph and colleagues have noted, this can prevent reflection, absorption, and retention of the lesson.14 Students need to feel safe when answering questions and be given the chance to learn in a nonthreatening environment.
DAILY EVENTS, TEACHABLE MOMENTS
Critical events are not the hallmark of debriefing in a clinical setting. Rather, occurrences throughout the day allow for rich discussion, reflection, and learning. To follow are examples in which instructors turn daily events into teachable moments by using debriefing techniques during the postclinical conference.
Administering medications provided by another nurse. After receiving morning report while on the clinical unit, a student approaches the instructor and says, “The night nurse just handed me Roxicet [oxycodone and acetaminophen] and said we should give it to the patient.” The instructor and student handle the situation per hospital policy, with the instructor immediately reporting the incident to the unit manager, who writes an incident report. Using the debriefing with good judgment approach, the instructor encourages the student to reflect on this event during the postclinical conference. She begins by asking the student, “How did you feel about the nurse handing you Roxicet?” This question leads to a discussion about accepting and administering medications provided by another nurse, the ethical implications of doing so, and best practices regarding handling such a situation. The instructor asks all students, “How would you feel if a coworker who was a friend handed you medication to administer?” This results in a conversation in which the instructor guides the students as they ponder the ramifications of errors in delivering medications prepared by another nurse.
Witnessing unprofessional behavior. Two students observe a patient receiving an abdominal wound packing by two experienced wound care nurses. The patient's wife is also in the room. The nurses are having a personal conversation and laughing as they change and dress the wound. During the postclinical conference, the students report this behavior to their instructor, who uses the debriefing for meaningful learning when asking, “What are your thoughts regarding what happened in the patient's room?” The students say they felt uncomfortable with the conversation taking place between the two nurses while they cared for the patient. The instructor then asks, “Do you feel comfortable sharing what was said in the room?” The students explain that the nurses ignored the patient while talking about their upcoming vacation plans. One student says, “The patient was in pain and needed assistance, and the nurses just kept talking.” The instructor listens to their concerns and says, “The nurses were having a personal conversation while attending to a patient. Does everyone agree this is not professional behavior?” As the students continue to discuss the scenario, the instructor listens and queries them about professionalism and patient advocacy.
Medication near miss. A student is assigned to retrieve a container of 5% dextrose in normal saline (D5NS) from the medication room. The student returns with a container of potassium chloride in D5NS. The instructor asks the student to verify the fluid container with the order. The student realizes the mistake and leaves to obtain the correct fluid container. In the postclinical conference, the instructor discusses intravenous fluids and utilizes debriefing methods associated with the PEARLS script. She asks the group, “How would you verify you have obtained the correct container of fluid?” This allows all the students to learn from this situation without embarrassing any one student. In approaching the topic in this manner, the instructor uses techniques that promote reflective thinking and learning.
ENRICHING THE LEARNING EXPERIENCE
As these scenarios illustrate, debriefing can be an important part of student learning in the clinical environment. Instructors should use the INACSL standards to guide their use of debriefing techniques during the postclinical conference. Doing so allows learners to engage with and reflect on clinical situations, enhancing their learning experiences. This, in turn, will guide them to deliver safe and effective care to their patients.
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