In this issue, Cheng et al1 adapt the Dreyfus and Dreyfus2 model of skill acquisition to present a conceptual framework for developing debriefing skills. The framework describes strategies for implementation across developmental stages termed: Discovery, Growth, and Maturity. Faculty development for debriefers in any learning setting is essential. Existing standards for simulation educators recognize the critical role of the debriefer in simulation-based educational experiences and recommend training and ongoing assessment of competence.3–5 The challenge of faculty development lies both with the individual—where do I begin? what do I work on next? and the organization—who to train, what to train, how to train?
The authors eloquently depict the development of debriefing skills through narratives and a thoughtfully articulated framework. Here, we aim to contextualize that developmental journey as one of personal growth requiring robust learning structures and purposeful implementation, and caution readers that development and progress may not be neat and linear. The same is true of the journey from theory and frameworks to application and implementation at the programmatic and organizational levels. We propose that uncertainty and experimentation are part of the journey and that individual, local, and cultural factors challenge a “one-size-fits-all” approach. Subsequently, we provide the construct of implementation science as a means to navigate the valuable lessons in this article at the organizational level.
When moving from a traditional teaching context (eg, classroom or clinical settings) to simulation-based teaching, clinician-educators often use the same techniques across all settings. As learners, many of us can recall the traditional approaches to teaching that viewed learners as empty vessels to be filled with information. Without available alternatives, well-intentioned educators can carry this same approach into debriefing. This approach misses the power of simulation as experiential learning and catalyst for reflection. Debriefing calls for a shift in thinking to a view of the learner as a maker of meaning, which places learning and the learner at the center. This is frequently a paradigm shift for educators, as they reconceptualize their role in the teaching learning interaction.6 In addition to this paradigm shift, the debriefer must also acquire skill in facilitating a debriefing discussion, posing reflective questions, synthesizing learning points, and responding to individual learning needs within the group. As Cheng et al1 point out so well, the development of these skills is a journey. As debriefers undertake this journey, there will be many moments of uncertainty and ambiguity, requiring their own resilience as they reflect on their growing skillset. There will also be many “aha” moments of new understanding as debriefers grapple with new concepts and approaches. Just as with new clinicians, there will be progress, mistakes, and painful learning experiences along the trajectory from novice to expert.
Described in this way, the trajectory from Discovery, through Growth, to Maturity, still sounds linear. There is an alternative paradigm for learning and development that can transform our view. Thinking of debriefing skills as a series of “threshold concepts” as described by Myer and Land7 unleashes new possibilities. Threshold concepts are ideas that, once fully understood, change forever the way a discipline is seen. Embedded in this conceptual journey is the experience of liminality—a state of becoming. In this state of becoming, a mindset that sees errors as triggers for reflective learning, not failures to be punished, will allow debriefers to “fail forward” on a pathway that ultimately moves steadily forward. Just as with our clinical learners, developing debriefers will benefit from a combination of didactic learning, reflection, and deliberate practice with feedback. Mostly, what they will benefit from is a bespoke development plan that is clear and supported by the organization.
IMPLEMENTATION IN ORGANIZATIONS
Organizations have a stake in ensuring that debriefers are developed in a deliberate, evidence-based way throughout the journey. Implementation science (IS) frameworks can guide the adoption integration of best practices into healthcare simulation settings. The Practical, Robust Implementation and Sustainability Model for IS argues that success and sustainability stem from thoughtful approaches to Adoption, Implementation, and Maintenance phases. At each phase, data are collected that evaluates the impact of intervention(s) on outcomes, observes for barriers to implementation, and identifies facilitators of uptake.8
Adapting the Practical, Robust Implementation and Sustainability Model to programs for faculty development in healthcare simulation allows us to think of these projects in a broader way: the intervention(s) (eg, foundational training, peer support, mentoring); the recipients (eg, debriefers); the external environment (eg, available resources); and the infrastructure available for implementation and sustainability (eg, funding, administrative support). The reach and effectiveness of the intervention flow from relationships between the recipients, infrastructure, and the external environment. These factors can vary widely between organizations, especially related to financial and human resources available. With the initiation of a new faculty development program, gathering data on both the implementation process and the effectiveness of the interventions is essential. This blended approach to data collection can provide organizations with the information needed to optimize training and overcome barriers to sustainability.9 Local leaders in simulation and faculty development may wish to incorporate Cheng et al's1 developmental milestones and strategies with an IS framework as they plan and allocate resources at each phase of the simulation program.
The challenge for many is a scarcity of resources. As the authors point out, a common approach to faculty development for debriefers is sending debriefers to a foundational course, with little or no formal follow-up. This “train-and-hope” approach to professional development is generally ineffective.10 The strategies proposed by Cheng et al1 while categorized for the Discovery, Growth, and Maturity phases of the individual instructors can also be conceptualized at the organizational level as sequential phases of Adoption, Implementation, and Maintenance. Table 1 provides several examples of implementation approaches in high- and low-resource settings and applies the strategies proposed by Cheng et al1 to the stage of implementation.
Debriefing is an essential part of the simulation-based learning experience. An organized approach to faculty development for debriefers is an important element in the overall success of a simulation program. By understanding the long-term trajectory of the development of debriefers, organizations can build a robust faculty development program that continually builds on extant skills, while striving for the authors' goal of adaptive expertise—the ability to adeptly respond to novel situations by creatively using their knowledge and skills.
1. Cheng A, Eppich W, Kolbe M, Meguerdichian M, Bajaj K, Grant V. A conceptual framework for the development of debriefing skills: a journey of discovery, growth and maturity. Simul Healthc
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