Clinical Simulation Research: The Role of the Presimulation Briefing
The healthcare simulation experience is comprised of several learning components, including both prebriefing and debriefing. Specifically, prebriefing is used to establish best practices and support a learner in their path to success — even before the medical simulation scenario has begun. Although the importance of thoughtful prebriefing has been recognized for years, research published in the Simulation in Healthcare: Journal of the Society for Simulation in Healthcare shares that elements and predicted effectiveness have not yet been blended into a set of promising practices. Seeking to formalize such practices into writing, this HealthySimulation.com article shares insight into the research, “Establishing a Safe Container for Learning in Simulation: The Role of the Presimulation Briefing.”
According to the research, a presimulation briefing (synonymous with the terms introduction, orientation, and prebriefing) for a healthcare simulation session or entire medical simulation course sets the tone for all that follows. A successful clinical simulation prebriefing experience is most often achieved when the effective instructor makes plain that the focus is on learning, not on “catching” people in a mistake. Instead, they seek to create an environment where participants feel safe, even inspired to share their goals, thought, or feelings about the upcoming simulation and debriefing.
To establish such prebriefing standards, authors Jenny W. Rudolph, Ph.D.; Daniel B. Raemer, Ph.D., and Robert Simon, EdD, organized a set of promising practices and identified them across closely related fields and within their own work. They argued that certain practices create a psychologically safe context for learning, also called a “safe container.” According to the authors, by establishing a safe container, learners are able to actively engage in a clinical simulation experience and debriefing, regardless of possible disruptions (such as unrealistic aspects of the simulation, potential threats to their professional identity, or frank discussion of mistakes.)
Further, as instructors collaborate with learners to perform these practices, the authors stress that consistency between what instructors say and do may also impact learners’ engagement. They explain that establishing a psychologically safe context includes the practices of (1) clarifying expectations, (2) establishing a “fiction contract” with participants, (3) attending to logistic details, and (4) declaring and enacting a commitment to respecting learners and concern for their psychological safety.
Additionally, this research notes that learning can be impeded when learners do not “buy-in” to the clinical simulation endeavor, or if they find the fidelity of the simulation problematic. Learning may also be impeded if learners do not feel exposed by the healthcare simulation and debriefing in a way that threatens their professional identity, and they feel defensive discussing performance that falls short of a standard. Thus, the authors pose the question: So what can instructors do to help create a safe container, an environment where learners face professionally meaningful challenges and are held to high standards in a way that engages them but does not intimidate or humiliate them?
Ultimately, they suggest establishing an environment where learners can enter a deep level of connection to their motivations, each other, and the instructor begins before the medical simulation starts. A crucial of engagement in health care simulation and debriefings, risk-taking in the service of learning is guided by a diverse set of research findings that stress a willingness of the learner to go to their social and intellectual edges with a positive attitude (1).
Important to note, psychological safety may not completely mitigate feelings of interpersonal risk. Rather, the authors explain that psychological safety tends to create a setting where learners feel safe enough to embrace being uncomfortable. The notion creates a setting where learners can practice new or familiar skills without the burden of feeling that they will be shamed, humiliated, or belittled, they share.
“Our literature review suggests that psychological safety is a crucial concept in determining whether a safe container has been created. If one feels psychologically safe, then one feels that the current environment is conducive to interpersonal risk-taking; learners feel that they will be viewed positively even if they make mistakes,” the authors explained within their research. “Psychological safety has been demonstrated to be a precursor to learning-oriented behaviors such as asking questions, sharing one’s thinking, and asking for help.”
While they stress that psychological safety has been extensively studied as a predictor of learning in groups, the authors reiterate that few studies have looked at the specific variables that create psychological safety. For example, leader inclusiveness, which includes behaviors such as inviting input and listening to and acknowledging subordinates’ ideas (or at least not shutting them down), has been posited as a precursor to psychological safety, they say. Thus, the authors hypothesized that practices such as these are within an instructor’s control and might contribute to psychological safety. In terms of methods for identifying promising practices, they identified and structured practices useful in presimulation briefing through three inputs:
- Synthesis of existing theory and research in fields closely related to simulation and debriefing
- From the exercise of developing an assessment of health care simulation briefing and debriefing
- The authors’ collective experience in conducting more than 6000 debriefings, hundreds of presimulation course briefings, as well as roughly 2000 instances of coaching other simulation instructors on the flow from prebriefing to simulation to debriefing.
Ultimately, through a review and synthesis of relevant concepts from literature with bearing on presimulation briefings, the authors proposed and discussed a set of promising practices that make up a sound presimulation course briefing and provide examples of these practices. While they cannot be sure that any one of the practices proposed or all of them together will always enhance engagement, they are supported conceptually by previous research and theory, our primary research on how to assess precourse briefings and debriefing, and our experience in healthcare simulation.
“We believe that a strong presimulation briefing begins the process of creating a safe container for learning that allows learners to tolerate and welcome direct and critical feedback, create opportunities to ‘redo’ a skill, work outside their comfort zone, accept and deal with surprises, change their current clinical practice, recast their current ways of thinking, and validate themselves as professionals,” the authors write.
Staw BM, Sandelands LE, Dutton JE. Threat-rigidity effects in organizational behavior: a multilevel analysis. Adm Sci Q 1981:26:501–524.
Lance Baily, BA, EMT-B, is the Founder & CEO of HealthySimulation.com, which he started while serving as the Director of the Nevada System of Higher Education’s Clinical Simulation Center of Las Vegas back in 2010. Lance is also the Founder and acting Advisor to the Board of SimGHOSTS.org, the world’s only non-profit organization dedicated to supporting professionals operating healthcare simulation technologies. His new co-edited Book: “Comprehensive Healthcare Simulation: Operations, Technology, and Innovative Practice” is available now. Lance’s background also includes serving as a Simulation Technology Specialist for the LA Community College District, EMS fire fighting, Hollywood movie production, rescue diving, and global travel. He lives with his wife Dr. Abigail Baily in Las Vegas, Nevada with their newborn daughter and two crazy dachshunds.