Taking Learning to the Next Level Beatrice Kastenbaum, RN, MSN, CNE Guided Reflection  for New Faculty © 2008 B. Kastenbau...
What is Guided Reflection? <ul><li>The active learner processes the simulated learning experience through rigorous self-re...
Who  participates in Guided Reflection? <ul><li>Students :  curious to learn, active, open, engaged, self-monitoring, self...
Sim from the Student’s Point of View <ul><li>Get prepared before coming </li></ul><ul><li>Get started—orient to simulation...
When  does Guided Reflection Occur? <ul><li>Immediately after the simulation </li></ul><ul><li>After a break </li></ul><ul...
Where  does Guided Reflection Occur? <ul><li>Simulation room itself </li></ul><ul><li>Viewing room </li></ul><ul><li>Clini...
Why  do Guided Reflection? <ul><li>Examine learning that occurred during the scenario in relation to the objectives </li><...
Who  should lead Guided Reflection? <ul><li>A.  Students </li></ul><ul><li>B.  Faculty </li></ul><ul><li>C.  Staff </li></...
A word about collaborative learning <ul><li>Gain student consent and thoughts about rules related to simulation and reflec...
Instructor’s Point of View <ul><li>Get prepared before coming—  Debriefing is scary! </li></ul><ul><li>Approach with curio...
Possible approaches <ul><ul><li>Judgmental—sage on the stage   </li></ul></ul><ul><ul><li>Non-judgmental  </li></ul></ul>...
What is a good starting place? <ul><ul><li>Thank the students for their participation.  </li></ul></ul><ul><li>Uncover ass...
Inquiring <ul><li>Story    meaning to student    meaning for future.  </li></ul><ul><ul><li>Tell us what happened  </li>...
Modeling feedback <ul><ul><li>Use observation guides such as a competency scale </li></ul></ul><ul><ul><li>Guide feedback ...
Think about learning styles <ul><li>Visual learners—use the board to make charts, review lab values, make a concept map. <...
Use the wisdom of the group <ul><li>Encourage discussion of alternatives </li></ul><ul><ul><li>“ What other ways could Sus...
Interruption/Redirection <ul><li>Use when negative vibes are occurring, </li></ul><ul><ul><li>“ Let’s go back to ___”   </...
Summarize <ul><li>Address misconceptions, inappropriate actions, missed assessment or interventions if not done earlier by...
Decisions <ul><li>To watch the video or not? </li></ul><ul><li>Should the students repeat the scenario?  </li></ul><ul><li...
Review :  What is happening during Guided Reflection? <ul><li>Debriefing </li></ul><ul><li>Reflecting </li></ul><ul><li>Th...
Disruptions to Reflection <ul><li>Student states: </li></ul><ul><ul><li>Manikin is not real, or confused about what is rea...
What now?? <ul><li>Is it defensiveness, preserving social “face”?  </li></ul><ul><li>Work to maintain trust and psychologi...
It is not self-preservation,  now what? <ul><li>Hear it and go past it.  </li></ul><ul><li>Reinforce the need to prepare f...
What about those who do not meet objectives? <ul><li>What were the objectives—formative or summative?  </li></ul><ul><li>D...
What detracts from learning in the Simulation Session? <ul><li>Lack of initial explanation of purpose, objectives, charact...
More bad habits <ul><li>Closed question, excessive criticism or negativism, caustic language </li></ul><ul><li>Mocking or ...
You wouldn’t do this… <ul><li>Allow discussion to focus on the limitations of simulation </li></ul><ul><li>Consume excessi...
Evaluation of Participation <ul><li>Formative or Summative ?  </li></ul><ul><li>Check lists—each element is assessed indiv...
Ways for Participants to evaluate learning: <ul><li>Self-evaluation  </li></ul><ul><li>View video together </li></ul><ul><...
合知 一行 <ul><li>Knowledge   </li></ul><ul><li>is the beginning of practice; </li></ul><ul><li>Action   </li></ul><ul><li>is ...
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  • Debriefing—has the connotation of having survived a crisis.
  • Students--Student characteristics: Teacher characteristics: Sim staff— Visitors—aware of the objectives of the simulation, sign an agreement to maintain student confidentiality, no war stories, not in sim room
  • Planning is when the clinical decision making is happening. Much of the learning happens during guided reflection.
  • Assign issues for later discussion or reflective journaling, link theory to simulation experience to practice. Delay can enhance learning because it allows for individual cognitive restructuring, and review.
  • Develop and strengthen habits in pausing to think, asking questions, articulation of thoughts, providing feedback to others.
  • but remember there is no single truth in a scenario. There will probably be unintended consequences. Take notes based on objectives, rubric, checklist, Watch for the unexpected.
  • Students are tuned into what the instructor thinks whether it is positive or negative. Try not to share a judgment but share a viewpoint of an issue that can lead to further discussion.
  • Cognitive structuring—how a memory is organized. usually an individual student activity, Instructor evaluates this verbally when meeting one-on-one, or in reflective journals and assignments.
  • Feedback—cite a standard, use a rubric for self grading, have student think aloud, have student tell you what their mental process is, Encourage collaboration among learners. Promote communication among team members—focus on capabilities, strengths, and weaknesses with the participants. Learning to share constructive feedback is an important part of the simulation experience.
  • Student may do additional reflection in their journaling. Academic voice can help student to recall and organize information.
  • Debriefing—dealing with knowledge, thoughts, and feelings after a crisis
  • If it were real I would have done it differently I would have had X available in a real situation. The simulator did not have (some important aspect of assessment—pupils, movement, quick verbal responses.) I don’t believe Mocking or humiliating actors Focusing on one aspect or detail excessively or flitting from issue to issue without depth
  • Examples—Air embolism check list, Clinical Competency Scale, SimMan lives or dies
  • Examples—Air embolism check list, Clinical Competency Scale, SimMan lives or dies RCT’s about 5 that I can find see Melnyk article.
  • The philosopher would probably agree that the circle of knowing and doing is helped along by reflection with a guide especially with an expert.
  • D Guided Reflectionfornewfaculty

    1. 1. Taking Learning to the Next Level Beatrice Kastenbaum, RN, MSN, CNE Guided Reflection for New Faculty © 2008 B. Kastenbaum RN, MSN, CNE
    2. 2. What is Guided Reflection? <ul><li>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 </li></ul><ul><li>Reflection is enhanced by the presence of the teacher/expert/mentor. </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    3. 3. Who participates in Guided Reflection? <ul><li>Students : curious to learn, active, open, engaged, self-monitoring, self-aware, self-confident </li></ul><ul><li>Faculty : knowledgeable, competent, role modeling the profession, active, engaged, self-monitoring, self-aware, self confident, open, warm, encouraging </li></ul><ul><li>Simulation staff : supportive, comfortable with the equipment, the process </li></ul><ul><li>Visitors : respectful of student learning </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    4. 4. Sim from the Student’s Point of View <ul><li>Get prepared before coming </li></ul><ul><li>Get started—orient to simulation environment, get report </li></ul><ul><li>“ Oh No! It is my turn.” </li></ul><ul><li>Assess the patient, wait for something to happen, diagnose the problem </li></ul><ul><li>PLAN ( make a clinical decision ) </li></ul><ul><li>Implement interventions </li></ul><ul><li>Get help if necessary </li></ul><ul><li>Evaluate and document care, APPLAUSE! </li></ul><ul><li>Whew!!! </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    5. 5. When does Guided Reflection Occur? <ul><li>Immediately after the simulation </li></ul><ul><li>After a break </li></ul><ul><li>Later, in clinical conference </li></ul><ul><li>Later, on a discussion board </li></ul><ul><li>Later, answering quiz questions </li></ul><ul><li>Later, answering a survey </li></ul><ul><li>Later, in a journal entry </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    6. 6. Where does Guided Reflection Occur? <ul><li>Simulation room itself </li></ul><ul><li>Viewing room </li></ul><ul><li>Clinical conference </li></ul><ul><li>Faculty office </li></ul><ul><li>On-line </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    7. 7. Why do Guided Reflection? <ul><li>Examine learning that occurred during the scenario in relation to the objectives </li></ul><ul><li>Resolve confusion and misconceptions resulting from the scenario </li></ul><ul><li>Examine values, assumptions, and knowledge that drive clinical decisions. </li></ul><ul><li>Focus on students’ mental models, actions and results in a safe place to consolidate learning and promote change in practice . </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    8. 8. Who should lead Guided Reflection? <ul><li>A. Students </li></ul><ul><li>B. Faculty </li></ul><ul><li>C. Staff </li></ul><ul><li>D. Visitors </li></ul><ul><li>The answer is: A. Students with help as needed from faculty. </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    9. 9. A word about collaborative learning <ul><li>Gain student consent and thoughts about rules related to simulation and reflection. </li></ul><ul><li>Do this before simulation starts (These rules might also guide clinical conference time.) </li></ul><ul><li>Topics might include: </li></ul><ul><ul><li>preparation, </li></ul></ul><ul><ul><li>group leadership, </li></ul></ul><ul><ul><li>how to offer feedback </li></ul></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    10. 10. Instructor’s Point of View <ul><li>Get prepared before coming— Debriefing is scary! </li></ul><ul><li>Approach with curiosity—What will the instructor learn today? </li></ul><ul><li>Get help when needed </li></ul><ul><li>Give feedback to other faculty and staff about the simulation experience. </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    11. 11. Possible approaches <ul><ul><li>Judgmental—sage on the stage  </li></ul></ul><ul><ul><li>Non-judgmental </li></ul></ul><ul><ul><ul><li>Use Socratic questioning </li></ul></ul></ul><ul><ul><ul><li>Develop based on objectives, </li></ul></ul></ul><ul><ul><ul><li>May not directly address what happened or mistakes </li></ul></ul></ul><ul><ul><li>Advocacy with Inquiry </li></ul></ul><ul><ul><ul><li>Share instructor’s viewpoint to initiate dialogue </li></ul></ul></ul><ul><ul><ul><li>Focus on objectives </li></ul></ul></ul><ul><ul><ul><li>Focus on all learners including teacher </li></ul></ul></ul><ul><ul><ul><li>Seek to make meaning of the situation </li></ul></ul></ul><ul><li>See handout: Rudolph et. al. “There is no such thing as non-judgmental debriefing” </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    12. 12. What is a good starting place? <ul><ul><li>Thank the students for their participation. </li></ul></ul><ul><li>Uncover assumptions about the situation </li></ul><ul><ul><li>How did it go? </li></ul></ul><ul><ul><li>What did you think was happening? </li></ul></ul><ul><li>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. </li></ul><ul><li>Can you tell us what guided your decision?” </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    13. 13. Inquiring <ul><li>Story  meaning to student  meaning for future. </li></ul><ul><ul><li>Tell us what happened </li></ul></ul><ul><ul><li>What did it mean when it happened? </li></ul></ul><ul><ul><li>How will you use this in the future? </li></ul></ul><ul><li>Plus/Delta— Write on board for visual folks. </li></ul><ul><ul><li>What went well? </li></ul></ul><ul><ul><li>What did not go well? </li></ul></ul><ul><ul><li>Be ready to wait after asking a question </li></ul></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    14. 14. Modeling feedback <ul><ul><li>Use observation guides such as a competency scale </li></ul></ul><ul><ul><li>Guide feedback that </li></ul></ul><ul><ul><li>is specific, and credible, based on a standard, </li></ul></ul><ul><ul><li>focuses on actions and effort, </li></ul></ul><ul><ul><li>identifies changes possible, </li></ul></ul><ul><ul><li>recognizes individual challenges, </li></ul></ul><ul><ul><li>does not distract from the objectives, </li></ul></ul><ul><ul><li>starts and ends positively </li></ul></ul><ul><ul><li>Share your own perceptions and judgments sparingly </li></ul></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    15. 15. Think about learning styles <ul><li>Visual learners—use the board to make charts, review lab values, make a concept map. </li></ul><ul><li>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. </li></ul><ul><li>When you see the light go on for a student, ask about it. </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    16. 16. Use the wisdom of the group <ul><li>Encourage discussion of alternatives </li></ul><ul><ul><li>“ What other ways could Susan have included the family?” </li></ul></ul><ul><li>Guide group to search for answers—send to resources rather than “giving” answers </li></ul><ul><ul><li>“ Good question. I am not sure I know the answer, let’s see what (name a resource or search strategy) will tell us?” </li></ul></ul><ul><li>Encourage each member to participate </li></ul><ul><ul><li>“ George, I wonder what you would do if _____?” </li></ul></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    17. 17. Interruption/Redirection <ul><li>Use when negative vibes are occurring, </li></ul><ul><ul><li>“ Let’s go back to ___” </li></ul></ul><ul><ul><li>“ What did you notice when ____” </li></ul></ul><ul><li>Use when topic is finished. </li></ul><ul><ul><li>“ Okay, moving on. What was happening when _____?” </li></ul></ul><ul><li>This is not impolite but expected of a facilitator. </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    18. 18. Summarize <ul><li>Address misconceptions, inappropriate actions, missed assessment or interventions if not done earlier by the group. </li></ul><ul><li>Ask how the group will use what they have experienced in real situations. </li></ul><ul><li>Not too short and not too long-- “Too much is too much” </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    19. 19. Decisions <ul><li>To watch the video or not? </li></ul><ul><li>Should the students repeat the scenario? </li></ul><ul><li>Ask yourself: What are the objectives and how will this enhance the students’ learning? </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    20. 20. Review : What is happening during Guided Reflection? <ul><li>Debriefing </li></ul><ul><li>Reflecting </li></ul><ul><li>Thinking critically </li></ul><ul><li>Checking assumptions </li></ul><ul><li>Looking for alternatives </li></ul><ul><li>Defending— not usually a word associated with this list. Has two connotations—defending ideas in a good way that enlightens listeners, and being defensive. </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    21. 21. Disruptions to Reflection <ul><li>Student states: </li></ul><ul><ul><li>Manikin is not real, or confused about what is real or not </li></ul></ul><ul><ul><li>Situation would never happen this way because… </li></ul></ul><ul><ul><li>Needed equipment did not work or was unavailable </li></ul></ul><ul><ul><li>Others were watching </li></ul></ul><ul><li>Students lack preparation and knowledge </li></ul><ul><li>Group acts bored or all knowing </li></ul><ul><li>Group dynamics interfere with trust needed for collaborative learning. </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    22. 22. What now?? <ul><li>Is it defensiveness, preserving social “face”? </li></ul><ul><li>Work to maintain trust and psychological safety for the students. </li></ul><ul><li>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. </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    23. 23. It is not self-preservation, now what? <ul><li>Hear it and go past it. </li></ul><ul><li>Reinforce the need to prepare for simulation as if preparing for a patient in clinical practice. </li></ul><ul><li>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. </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    24. 24. What about those who do not meet objectives? <ul><li>What were the objectives—formative or summative? </li></ul><ul><li>Deal with individual behavior or knowledge deficits individually. </li></ul><ul><li>Have high expectations, expect preparation, good effort and collaboration. </li></ul><ul><li>Deal with group personality problems separately. </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    25. 25. What detracts from learning in the Simulation Session? <ul><li>Lack of initial explanation of purpose, objectives, characteristics and use of the manikin </li></ul><ul><li>Lack of preparation by participants or faculty </li></ul><ul><li>Lack of engagement by any members of the group </li></ul><ul><li>Underestimating participant emotions </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    26. 26. More bad habits <ul><li>Closed question, excessive criticism or negativism, caustic language </li></ul><ul><li>Mocking or humiliating team members by any member of the group </li></ul><ul><li>Autocratic attitude of the teacher </li></ul><ul><li>Excessive instructor discussion, too little student participation </li></ul><ul><li>Highlighting too many key teaching points </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    27. 27. You wouldn’t do this… <ul><li>Allow discussion to focus on the limitations of simulation </li></ul><ul><li>Consume excessive time </li></ul><ul><li>Omit the summary at the end of guided reflection to reinforce learning of best practices and eliminate misconceptions about correct actions </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    28. 28. Evaluation of Participation <ul><li>Formative or Summative ? </li></ul><ul><li>Check lists—each element is assessed individually—Straight catheter insertion </li></ul><ul><li>Global rubric—elements are categorized and judged as by grouping—Competency Scale </li></ul><ul><li>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? </li></ul><ul><li>Nolan, T and Berwick, D. (2006) All-or-None Measurement Raises the Bar on Performance. JAMA 1168-1170. </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    29. 29. Ways for Participants to evaluate learning: <ul><li>Self-evaluation </li></ul><ul><li>View video together </li></ul><ul><li>Quizzes or other written assessment of knowledge </li></ul><ul><li>Repeat simulation </li></ul><ul><li>Clinical observations </li></ul><ul><li>Student surveys/satisfaction –On Bb for each course </li></ul><ul><li>Anecdotal reports (I did this in sim and then …) </li></ul><ul><li>Compare expert (EBP) to actual performance </li></ul><ul><li>RCT’s </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE
    30. 30. 合知 一行 <ul><li>Knowledge </li></ul><ul><li>is the beginning of practice; </li></ul><ul><li>Action </li></ul><ul><li>is the completion of knowing. </li></ul><ul><li>Adapted from The Philosophy of Wang Yang-ming, (1916) translated by Frederick Goodrich Henke. Open Court Publishing Co. New York </li></ul>© 2008 B. Kastenbaum RN, MSN, CNE

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