It is widely accepted that the debriefing process is the most important component of simulation-based education1; however, in recent years, the importance of prebriefing has become more recognized.2–6 Although the prebriefing is often overlooked, it prepares learners for a successful simulation and an optimal learning experience,7 and prebriefing has been identified as a key element in a successful learning experience for a productive debriefing.8 Chamberlain9 questioned whether the prebriefing stage of a simulation-based learning experience is equal to the debriefing stage in the importance it plays related to student learning and reflection.
Prebriefing is defined as, “an information or orientation session held prior to the start of a simulation activity in which instructions or preparatory information is given to participants … to set the stage for a scenario, and assist participants in achieving scenario objectives.”10(p.27) Rudolph et al11 assert that the role of prebriefing, or presimulation briefing, is to attend to the psychological safety of learners. The authors argue that creating a safe environment at the start of the simulation (a) sets the tone for the entire simulation experience, (b) reduces insecurity and assists learners to feel comfortable with risk-taking and making mistakes, and (c) averts defensive behaviors. Creating a safe environment facilitates the rapport between the facilitator and learner and contributes to a conductive learning environment during debriefing.12 Prebriefing should establish simulation ground rules that inform all learners of the mutual expectations of the learning experience.13 Facilitators need to be aware of the potential fears and apprehensions that learners may experience before participating in a simulation-based learning activity, and learners may become defensive if they perceive a discrepancy between their educational expectations and their training experiences.14
At the start of this project, a list of professional simulation organizations was compiled by the authors, and a comprehensive search for standards and guidelines related to prebriefing was completed by researching each organizations web address. A medical librarian completed literature searches in the following 7 databases: PubMed, CINAHL, ERIC (EBSCO), PsycINFO, PsycARTICLE, and Cochrane Database of Systematic Reviews. An illustration of each database with search terms, filters, and relevant results returned is provided (see Table, Supplemental Digital Content 1, http://links.lww.com/SIH/A465, which shows search terms and relevant results returned for databases). ProQuest was searched, which yielded one dissertation related to prebriefing. In total, 93 articles were reviewed for standards and guidelines pertaining to prebriefing. Most articles focused only on debriefing with 9 articles specific to or including prebriefing recommendations. Of those 9 articles, only 3 were research based.
The 9 articles, along with simulation organizations standards and guidelines, were used to create a single document outlining the established elements for prebriefing. No additional content was added that was not already part of prior guidelines or literature. The list represents a compilation of the reviewed literature; although not all sources listed all items, no conflicts were noted. The initial checklist was piloted at an international simulation conference workshop with approximately 80 participants; each element was discussed then refined after conference for this article.
Figure 1 is a prebriefing infographic that aims to serve as a cognitive aid and support educator training. It contains categories and items that can be addressed in prebriefing. Thought balloons and stems are provided to assist facilitators to know what to say in prebriefing. Figure 2 is a facilitator prebriefing checklist of the essential elements. The source of each element is referenced in Figure 2 to delineate where the item originated.
Learners are often apprehensive before a simulation experience.15–18 Nielen and Harder16 concluded that anxiety before a simulation can interfere with the learning process and ultimately decrease the effectiveness of simulation as learning technique. Fraser et al19 concluded that anxiety can produce a negative relationship between cognitive load and performance in simulation. Interventions to reduce anxiety and improve performance during simulation have been reported in the literature. Gosselin20 concluded that listening to music before a simulation has the potential to reduce anxiety, improve performance, and facilitate learning, whereas Gantt21 suggested that preparing learners for simulation reduces learners' anxiety. Prebriefing can provide learners the preparation needed to decrease anxiety and prepare for a successful simulation experience.
A quasi-experimental study completed by Kim et al22 found that learners who were given interventions, such as verbal orientation outside the simulation room, an orientation of the simulation environment, and a nursing skill practice station in an open laboratory before the simulation-based learning experience, had significantly higher flow (fluency of performance and absorption by activity) and self-confidence compared with groups who only received 1 or 2 of the interventions. Another study found that nursing students' perceptionsof overall simulation effectiveness, learning, and self-confidence were significantly higher with the use of prebriefing compared with no prebriefing.2 Page-Cutrara23 found a structured prebriefing with guided reflection and concept mapping superior to traditional prebriefing. The author reported significant differences in competency performance, clinical judgment, and prebriefing experience between groups of learners. These studies provide the basis for the research completed about prebriefing. The research related to prebriefing is largely based on learner feedback and lacks findings that include higher-level, more objective data.
There is a gap in the literature related to prebriefing; there is a need for a document that outlines the essential elements ofprebriefing. Without a complete list of essential elements to include at the beginning of a simulation-based learning experience, the facilitator may leave out important and vital information that is necessary to support success for the learner. Furthermore, facilitators, educators, clinicians, and researchers may better study, develop, and embrace elements of prebriefing with a comprehensive list of evidence-based prebriefing practice elements to advance the science of healthcare simulation. The purpose of this article is to (a) report current established prebriefing standards and guidelines, (b) compile the essential elements recommended into one document to serve as a cognitive aid and facilitate educator training, and (c) to discuss additional areas of inquiry and research needed in relation to prebriefing.
Standards and guidelines on the established essential elements to include in a prebriefing are outlined in the literature by simulation organizations.24–29 Some of the elements identified in the guidelines are similar and appear consensual, whereas some bring out additional ideas, and others focus the guidelines toward the subject, content, or purpose of the organization. There are also authors who have addressed prebriefing guidelines.11,13 The authors provide a comparison of the established prebriefing standards and guidelines by simulation organizations and experts (see Table, Supplemental Digital Content 2, http://links.lww.com/SIH/A466, which demonstrates simulation organizations support for prebriefing).
Setting the Scene
Setting the scene includes elements, such as psychological safety, fiction contract, confidentiality, communication, and logistics. According to Rudolph et al,11 the presimulation briefing (or prebriefing) should focus on establishing a psychologically safe place for learning. The authors contend that this is done by clarifying expectations, establishing a “fiction contract” with participants asking them to accept the simulation scenario as real, attending to logistic details (length of simulation time, where, standardized patient [SP] or manikin, etc), and declaring and enacting a commitment to respecting learners and concern for their psychological safety. The elements mentioned are part of the Debriefing Assessment for Simulation in Healthcare, a behaviorally anchored rating scale on briefing and debriefing,30 and the International Nursing Association for Clinical Simulation and Learning (INACSL) Standards of Best Practice: Simulation Facilitation31 under Criterion 3. This criterion also requires the prebriefing to include information and direction regarding how communication will occur during the simulation in addition to acknowledging the acceptance of making mistakes in a noncompetitive, nonthreatening learning environment.
The prebriefing session should include expectations of the simulation facilitator in addition to participant (student) expectations. The INACSL Standards of Best Practice: Simulation Facilitation31 and INACSL Standards of Best Practice: Simulation Professional Integrity32 both note the importance of clear communication and maintaining a safe learning environment and confidentiality. It is during the prebriefing that the simulation facilitator can communicate and role model expectations of professional integrity, ethics, and following standards of best practice. The facilitator needs to communicate the institutions' policies and procedures for conduct during a simulation, fair and unbiased evaluation, video-taping, and how feedback of simulation performance will or will not be shared. In addition, the student expectations are also outlined during the prebriefing, which include many of the same elements: professional integrity, following standards of best practice, professional etiquette and respect for others, and agreement to following the institutions' simulation policies and procedures.
In debriefing, the purpose of the simulation, methods, and process are integral to support this element. Facilitators should use the objectives to guide the process and their questions to enhance discovery learning.11,13,24,33,34 The purpose may be brief or extensive dependent on the level of the learner.31,33,34 The methods should be preselected and evidence based.11,13,34
The simulation scenario is another area that should be part of prebriefing. Here, the facilitator will provide participants the backstory for the simulation scenario.24,27 This may be an end of shift report, a patient history, or whatever information the participant needs to know about the patient or scenario he or she is about to encounter in the simulation experience.
Some facilitators may assign roles to participants.25,27 The roles may vary depending on the participants' discipline. However, the INACSL Standards of Best Practice: Simulation Facilitation27 states that clear guidelines of all assigned roles should be provided to participants.
Many organizations and authors discuss the need to provide participants with objectives of the simulation.11,24,25,27,28 The INACSL Standards of Best Practice: Simulation Outcomes and Objectives state that objectives should be constructed to be specific, measurable, achievable, realistic, and time phased.33 Others concur that objectives need to be clear28 and explicitly clarified.11 Objectives may be for individual learners or teams of learners.24
In addition, part of the prebriefing needs to include information regarding evaluation.11,24,35 Rudolph et al11 point out the importance of sharing how and if the participants' performance will be evaluated and the connection to establishing the safe container for learning. The evaluation of the participant should be directed by the objectives and guided by the type (formative, summative, or high-stakes).11,35 Participants need to understand that in formative evaluation, the debriefing is for all participants to reflect on the case and to learn from each other, whereas with summative and/or high-stakes evaluation, participants may receive feedback about the achievement of outcomes or competencies demonstrated in the simulation.35 Summative or high-stakes evaluation may include a grade or consequence if a certain score or level of competency is not demonstrated.35 There may also be an evaluation of the simulation itself.24
Simulation Room Orientation
Simulation room orientation allows a practical understanding of the location of supplies, vision of how they will interact with their environment, and enables them to operate the equipment reviewed.24,25,31,34 The INACSL standards additionally state that method of evaluation, roles, timing, case overview, and limitations of the simulations should be discussed in the prebrief.34
The INACSL Standards of Best Practice: Simulation Facilitation27 includes providing time for participants to prepare as part of prebriefing. The organization notes this element of prebriefing as “as appropriate.” Depending on the evaluation method, this element may or may not be applicable to the simulation learning experience.
There are many questions still left unanswered related to prebriefing and how it can best facilitate learning in simulation. Experts and organizations have produced standards and guidelines to facilitate the prebriefing, but it is important to remember that these are mostly recommendations and a collection of best practices.
Although essential elements have been identified, it is unknown whether the order of the elements makes a difference in learning outcomes of the simulation. The authors have provided items on the Prebriefing Infographic (Fig. 1) and the Faculty Prebriefing Checklist (Fig. 2) in an order that is useful in their experience, but facilitators may elect to change this order depending on the type of learners or simulation scenario details. There is currently no research to show the order in which elements should be discussed in prebriefing, although most facilitators begin by attending to psychological safety.11
There are also no guidelines on whether a prebriefing needs to occur at the start of every simulation when learners are participating in a sequence of simulations. In the authors' experience, a full prebriefing that includes all the essential elements must occur at the start of the initial simulation. In subsequent simulations on the same day, the facilitator may opt to shorten the prebriefing to include what he or she determines to be most crucial to remind participants, such as psychological safety.
As Rudolph et al11 pointed out that discussing confidentiality helps establish the safe learning environment. Some institutions have learners sign a confidentiality form to prevent postsimulation discussions about the scenario or any events that occur during the simulation. This not only protects the scenario case and allows all learners to have the same learning opportunity but also establishes trust within the group of learners. Some facilitators verbally equate to learners confidentiality (or the signing of a confidentiality form) in the simulation setting to the Health Insurance Portability and Accountability Act36 in real clinical settings. Although it is thought by many facilitators that this connects the importance of maintaining confidentiality in the simulation setting in the learners mind, it is unknown whether this reinforces the importance of confidentiality in the simulation setting.
Learners may be given preparatory activities before the simulation experience.31 The literature speaks to the use of preparatory activities before a simulation.37,38 However, it is unclear whether this is a part of the prebriefing process immediately before the simulation. Although Chamberlain39 states that this is a “common prebriefing process,” it seems that these activities are done before the day of the simulation, and her model case exemplar does not include the facilitator discussing the preparatory activities with the learners on the actual day of the simulation. One could conclude that preparatory activities are given before the day of simulation and are not an official part of the prebriefing time. However, anecdotal conversations with facilitators have revealed that some spend 45 minutes to an hour discussing preparatory activities before the simulation.There is confusion in the literature about the use of preparatory activities, including whether this is a part of prebriefing, and what effect(s), if any, the use of preparatory activities has on the learner.
We have observed poor or inconsistent orientations where learners spent much of the time searching for items or trying to make different types of equipment work without progress in the scenario. Notably, these were not the planned objectives for the simulation. Orientation should be completed in an organized manner. In particular, to set learners up for success, facilitators may choose to record a video to standardize the orientation for multiple groups. The INACSL states “Consider use of a written or recorded prebriefing plan to standardize the process and content for each scenario/case. A written or recorded prebriefing plan should be required for simulation-based experiences when used for high-stakes evaluations.”34 Recording can provide orientation to a standard room without learners seeing cues for the actual case. For example, each orientation begins on the left side of the room and orients from left to right covering identified equipment and locations of supplies for that simulation. Operationally, orientations can be enhanced by setting up simulation cases and rooms consistently: label drawers and shelves on the outside to limit searching time and allow participants to settle quicker into the room and remain in role. Also consider adding a case specific orientation section to your simulation template to provide consistency in items that need to be covered for that particular case (based on the design and objectives).
One of the essential elements of prebriefing is to provide learners an orientation to the simulation environment, location of equipment that may be required during the scenario, and the manikin/task trainer functionalities.17 It is sensible to think that this activity will assist the learner in the simulation; however, there is no empirical evidence to support this assumption. It is unclear what the effect(s) this has on the learner. In simulation practice, it is clear that it affects the time it takes to complete the simulation, but does this matter? Does it mimic real clinical practice? Does orientation to the simulation environment decrease the anxiety that learners may experience with simulation? Or does this increase the anxiety once the learner steps into a room with a manikin or standardized patient, potentially sees a 2-way mirror and/or notices that cameras are placed to record the simulation? It is unclear what effects there are on the learner and learning outcomes by providing time for learners to scout out the simulation room and become familiar with the manikin. In addition, it might be important to know whether facilitators experience anxiety or if they recognize an increase in anxiety in learners, and, if so, how this is addressed. These are important questions that need to be investigated.
Another area where further inquiry is needed relates to prebriefing with staff and SPs on the day of the simulation. Anecdotal evidence suggests that a planned prebriefing between the facilitator and staff immediately before the learner prebriefing provides a unique opportunity to quickly review roles, objectives, written performance measures, room set up and equipment, and cueing. The facilitator and staff prebriefing can resolve gaps in mutual expectations, address operational details, and reveal and remediate unintentional communication errors, leading to a more successful simulation experience learners.
A prebriefing with SPs may also help ensure a successful simulation experience for the learner. Standardized patient best practices include formal case training and review with an SP trainer on each case to ensure quality, consistency, accuracy of portrayal, and demonstrated understanding of the role.16 The ASPE Standards of Best Practice16 Principle 3.1.3 requires the “creation of a training plan that is responsive to the context and format of each activity,” and Principle 3.2 addresses training for role portrayal, which details content.(p.6) However, the Standards of Best Practice does not reference timing of the training, providing another area for additional inquiry. In addition, scheduling limitations may restrict formal training immediately before a simulation, yet a short prebriefing can quickly assist the SP to refresh details related to the patient role. A prebriefing between the facilitator, staff, and SP(s) may improve accuracy of the role portrayal and improve the quality and consistency of the simulation.
An item considered promising but not prominent in the literature, which authors have seen positive results in facilitation with, is during prebriefing, sharing the method of debriefing with the learner. This includes process, phases, and timing for debriefing. The authors have anecdotally experienced additional learner benefits, increased buy-in, and satisfaction by the learners. Notable are appreciation and respect from the learners for sharing the knowledge and using and disclosing the process. Furthermore, learners have been observed transferring the debriefing process into their own practice in clinical situations and even using the same language role modeled by facilitators. In our experience, including and explaining the value, phases, and purpose of the debriefing during the prebriefing instills professional briefing skills and allows transference and understanding of a quality improvement process, which should improve communication in clinical practice. This in addition to facilitation practice has the potential to transform patient care.
A limitation of the checklist is that it is designed broadly to comprehensively cover formative simulation. There are situations where the checklist may need to be amended depending on the level of the learners or the type of evaluation for the simulation. For summative and high-stakes simulations, some of the elements may need to be omitted. Demonstrating features of a piece of equipment in the simulation room, providing specific objectives, and/or assigning roles may give away the scenario and guide learners to the learning outcomes. The simulation educator should use their professional judgment based on the objectives and design of the simulation as to which elements need to be included in the scenario-specific prebriefing. Sometimes, it may be useful to brief learners about a piece of equipment even it is not actually required during the scenario. Participants may still learn something new from this and will realize that everything that is presented to them is not necessarily a clue about the scenario.
It is important that essential elements are provided to learners in the prebriefing. This prepares them for a successful simulation and an optimal learning experience. Although several simulation organizations and authors have provided various levels of prebriefing standards, more research is needed regarding what prebriefing should include, effects of preparatory activities, and effects of prebriefing on learning outcomes. Standardization of prebriefing terminology (ie, briefing vs. prebriefing and when the prebriefing session begins) is an area that needs further clarification and discussion. To advance research, there must be agreement in the lexicography so it may be reported and studied, and best practices further compared and identified. Additional rigorous research studies on each element are recommended to expand the current guidelines for prebriefing, provide standardized training to advance the science of simulation, and measure the impact of each element on learning outcomes.
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