Engagement in Distance Healthcare Simulation Debriefing: A Concept Development and Framework.

SUMMARY STATEMENT: Understanding distance health care simulation debriefing is crucial in light of the increased use of and emerging technology in remote education for reasons of accessibility, global collaboration, and continuous professional development. This article is a confluence of a number of previously published studies designed to serve as a foundation to develop the concept of "engagement in health care distance simulation debriefing" using the Schwartz-Barcott & Kim hybrid mixed methods model. The model uses 3 phases: theoretical (a realist systematic review of the literature), fieldwork (3 exploratory studies and 2 pilot experimental studies), and analytical (analysis of the theoretical and fieldwork findings through expert discussion). This study defines the concept of "engagement in health care simulation distance debriefing" through exploration of its uses and analysis in literature, interviews, and expert review. The hybrid approach to the analysis provided rigor to generate a new, reflective conceptual model. This conceptual model defines the complexity in engagement during distance debriefing and helps shape the development of simulationists and debriefers, leading to more effective distance simulations and debriefings.

Human factors considerations in distance simulation: A nominal group technique application.

INTRODUCTION: The pandemic-driven surge in global distance simulation (DS) adoption highlighted the need for effective educator training. A literature search identified the gap regarding human factors (HF) considerations for the professional development of DS practitioners. This study addresses this gap by applying HF principles to guide educators in developing and delivering evidence-based DS. METHODS: This was a consensus-gathering, three-phase study using the nominal group technique (NGT) in the first phase, qualitative thematic analysis with member checking in the second phase and external expert opinion in the third. A dichotomised approach was used to divide the post-consensus discussion survey results into an agreement and non-agreement for quantitative analysis. RESULTS: The results of the quantitative analysis identified the following needs: developing a conceptual framework for DS, tailoring the technical aspect to the educational objectives, investigating learner engagement, training faculty at an earlier stage and identifying at-risk students. Qualitative results identified primary themes of technology, people and outcome measurements. Key aspects of technology were identified as system- and programme-fit and resource considerations. Outcome measurement highlights the need for increased measurement and research at all levels of DS. DISCUSSION: Specific HF focal points include human-technology interaction and learning outcome assessment within the DS context. Incorporating HF principles throughout the DS process, from inception to outcome evaluation, promises substantial benefits for both learners and educators. This approach empowers both learners and educators, fostering a dynamic and enriched educational environment and improved learning experiences.

Society for Simulation in Healthcare Guidelines for Simulation Training.

BACKGROUND: Simulation has become a staple in the training of healthcare professionals with accumulating evidence on its effectiveness. However, guidelines for optimal methods of simulation training do not currently exist. METHODS: Systematic reviews of the literature on 16 identified key questions were conducted and expert panel consensus recommendations determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. OBJECTIVE: These evidence-based guidelines from the Society for Simulation in Healthcare intend to support healthcare professionals in decisions on the most effective methods for simulation training in healthcare. RESULTS: Twenty recommendations on 16 questions were determined using GRADE. Four expert recommendations were also provided. CONCLUSIONS: The first evidence-based guidelines for simulation training are provided to guide instructors and learners on the most effective use of simulation in healthcare.

Understanding the Effects of Health Care Distance Simulation: A Systematic Review.

ABSTRACT: The use of distance simulation has rapidly expanded in recent years with the physical distance requirements of the COVID-19 pandemic. With this development, there has been a concurrent increase in research activities and publications on distance simulation. The authors conducted a systematic review of the peer-reviewed distance health care simulation literature. Data extraction and a risk-of-bias assessment were performed on selected articles. Review of the databases and gray literature reference lists identified 10,588 titles for review. Of those, 570 full-text articles were assessed, with 54 articles included in the final analysis. Most of these were published during the COVID-19 pandemic (2020-2022). None of the included studies examined an outcome higher than a Kirkpatrick level of 2. Most studies only examined low-level outcomes such as satisfaction with the simulation session. There was, however, a distinction in studies that were conducted in a learning environment where all participants were in different locations ("distance only") as compared with where some of the participants shared the same location ("mixed distance"). This review exclusively considered studies that focused solely on distance. More comparative studies exploring higher level outcomes are required to move the field forward.

Health Care Simulation in Person and at a Distance: A Systematic Review.

ABSTRACT: Distance simulation is a method of health care training in which the learners and facilitators are in different physical locations. Although methods of distance simulation have existed in health care for decades, this approach to education became much more prevalent during the COVID-19 pandemic. This systematic review studies a subset of distance simulation that includes combined in-person and distance simulation elements, identified here as "mixed- distance simulation." A review of the distance simulation literature identified 10,929 articles. Screened by inclusion and exclusion criteria, 34 articles were ultimately included in this review. The findings of this review present positive and negative aspects of mixed-distance simulation formats, a description of the most frequent configurations related to delivery, terminology challenges, as well as future directions including the need for faculty development, methodological rigor, and reporting details.

Development of Distance Simulation Educator Guidelines in Healthcare: A Delphi Method Application.

INTRODUCTION: The abrupt disruption of in-person instruction in health care during the COVID-19 pandemic resulted in the rapid adoption of distance simulation as an immediate alternative to providing in-person simulation-based education. This massive instructional shift, combined with the lack of educator training in this domain, led to challenges for both learners and educators. This study aimed to disseminate the first set of competencies required of and unique to effective distance simulation educators. METHODS: This was a multiphasic and iterative modified Delphi study validating the content of carefully and rigorously synthesized literature. Experts were invited from around the globe to participate in this study with mandatory attendance at an annual health care simulation conference to openly discuss the guidelines presented as competencies in this document. We divided each competency into "Basic" and "Advanced" levels, and agreement was sought for these levels individually. The experts provided their opinion by choosing the options of "Keep, Modify, or Delete." A free-marginal kappa of 0.60 was chosen a priori. RESULTS: At the conclusion of the Delphi process, the number of competencies changed from 66 to 59, basic subcompetencies from 216 to 196, and advanced subcompetencies from 179 to 182. CONCLUSIONS: This article provides the first set of consensus guidelines to distance simulation educators in health care, and paved the way for further research in distance simulation as a modality.

What do you think of when you hear the word 'feedback'? A reflective thematic analysis study of interviews.

PURPOSE: Although most teaching around feedback focuses on the delivery, one must consider that the word 'feedback' is not a neutral word. It inflicts a range of emotions that, when used, may influence the effectiveness of the feedback process. A more profound understanding of health professions educators' perceptions regarding the word 'feedback' can help explain discrepancies between the provision, reception and acceptance of feedback. METHODS: This is a qualitative inductive, reflective thematic analysis study. The authors interviewed 22 health professions educators participating in an online workshop to develop their feedback giving skills on their initial perspectives of the word 'feedback'. RESULTS: We found four major themes: (1) Can I tell you a little story about my feedback experience? (2) It is probably going to be negative. (3) There is always something to learn if you are willing to hear the message. (4) It is like getting a report card. From the data, we suggest one key antecedent and two practical approaches one could take when giving feedback. CONCLUSION: In this article, the authors highlight barriers during the feedback process due to the mere perception of the nature of feedback and the connotations associated with the term itself and suggest approaches that can refocus conversations towards a shared meaning and purpose of improvement, despite the preconceptions of the word 'feedback'.

Distance simulation in the health professions: a scoping review.

BACKGROUND: Distance simulation is defined as simulation experiences in which participants and/or facilitators are separated from each other by geographic distance and/or time. The use of distance simulation as an education technique expanded rapidly with the recent COVID-19 pandemic, with a concomitant increase in scholarly work. METHODS: A scoping review was performed to review and characterize the distance simulation literature. With the assistance of an informationist, the literature was systematically searched. Each abstract was reviewed by two researchers and disagreements were addressed by consensus. Risk of bias of the included studies was evaluated using the Risk of Bias 2 (RoB 2) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tools. RESULTS: Six thousand nine hundred sixty-nine abstracts were screened, ultimately leading to 124 papers in the final dataset for extraction. A variety of simulation modalities, contexts, and distance simulation technologies were identified, with activities covering a range of content areas. Only 72 papers presented outcomes and sufficient detail to be analyzed for risk of bias. Most studies had moderate to high risk of bias, most commonly related to confounding factors, intervention classification, or measurement of outcomes. CONCLUSIONS: Most of the papers reviewed during the more than 20-year time period captured in this study presented early work or low-level outcomes. More standardization around reporting is needed to facilitate a clear and shared understanding of future distance simulation research. As the broader simulation community gains more experience with distance simulation, more studies are needed to inform when and how it should be used.

Principles of Justice, Equity, Diversity, and Inclusion in Health Care Distance Simulation Education: Consensus Building via the Nominal Group Technique.

PURPOSE: Health care distance simulation (HCDS) replicates professional encounters through an immersive experience overseen by experts and in which technological infrastructure enriches the learning activity. As HCDS has gained traction, so has the movement to provide inclusive and accessible simulation experiences for all participants. However, established guidelines for best practices in HCDS regarding justice, equity, diversity, and inclusion (JEDI) are lacking. This study aimed to generate consensus statements on JEDI principles in synchronous HCDS education using the nominal group technique (NGT). METHOD: Professionals with experience in HCDS education were invited to generate, record, discuss, and vote on ideas that they considered best practices for JEDI. This process was followed by a thematic analysis of the NGT discussion to provide a deeper understanding of the final consensus statements. An independent group of HCDS educators individually reviewed and recorded their agreement or disagreement with the consensus statements created by the NGT process. RESULTS: Eleven independent experts agreed on 6 key practices for JEDI in HCDS. Educators need to (1) be aware of JEDI principles, (2) be able to define and differentiate JEDI, (3) model JEDI in their environment, (4) have expertise and comfort facilitating conversations and debriefing around JEDI issues, (5) be advocates within their organizations to ensure equitable educational experiences, and (6) achieve JEDI without compromising educational objectives. Experts were divided on the approach to technology to ensure equitable learning experiences: some believed that the most basic technology accessible to all learners should be used, and some believed that the technology used should be determined by the competency of the students or faculty. CONCLUSIONS: Structural and institutional barriers in HCDS education persist despite agreement on key JEDI practices. Conclusive research is needed to guide the optimal policy in HCDS toward creating equitable learning experiences while bridging the digital divide.

Perspectives on developing moral courage in pre-licensure education: A qualitative study.

BACKGROUND: Error reporting and speaking up are mechanisms to reduce the incidence of healthcare errors. However, organizational policies don't always align with individuals' perceptions and beliefs to promote these mechanisms. When this misalignment produces fear, moral courage, which is taking action regardless of personal consequences, becomes necessary. Teaching moral courage in pre-licensure education may set a foundation for individuals to speak up in post-licensure careers. AIM: To explore health professionals' perceptions of healthcare reporting and organizational culture to inform pre-licensure education on how to promote moral courage. METHODS: Thematic analysis of four semi-structured focus groups with fourteen health professions educators followed by in-depth, semi-structured individual interviews. FINDINGS: Organizational factors, characteristics that an individual must possess to enact moral courage and priority methods to guide moral courage were identified. CONCLUSIONS: This study outlines the need for leadership education in moral courage and offers educational interventions to promote reporting and aid in developing moral courage academic guidelines to improve healthcare error reporting and speaking up behaviors.

Individual Characteristics That Promote or Prevent Psychological Safety and Error Reporting in Healthcare: A Systematic Review.

Background: Healthcare errors continue to be a safety issue and an economic burden that causes death, increased length of stays, and emotional trauma to families and the person who commits the error.  Speaking up and error reporting within a safety culture can reduce the incidence of error; however, this is complex and multifaceted. Aim: This systematic review investigates individual characteristics that support or prevent speaking up behaviors when adverse events occur.  This study further explores how organizational interventions designed to promote error reporting correlate to individual characteristics and perceptions of psychological safety.  . Methods: A systematic review of peer-reviewed articles in healthcare that contain characteristics of an individual that promote or prevent error reporting was conducted. The search yielded 1233 articles published from 2015 to 2021. From this set, 81 full-text articles were assessed for eligibility and ultimately extracted data from 28 articles evaluated for quality using Joanna Briggs Institute critical appraisal tools©. Principal Findings: The primary themes for individual character traits, values, and beliefs that influence a person's decision to speak up/report an error include self-confidence and positive perceptions of self, the organization, and leadership. Education, experience and knowledge are sub themes that relate to confidence. The primary individual characteristics that serve as barriers are 1) self-preservation associated with fear and 2) negative perceptions of self, the organization, and leadership. Conclusion: The results show that an individual's perception of their environment, whether or not it is psychologically safe, may be impacted by personal perceptions that stem from deep-seated personal values. This exposes a crucial need to explore cultural and diversity aspects of healthcare error reporting and how to individualize interventions to reduce fear and promote error reporting.

Setting an Agenda: Results of a Consensus Process on Research Directions in Distance Simulation.

BACKGROUND: The COVID-19 pandemic forced rapid implementation and refinement of distance simulation methodologies in which participants and/or facilitators are not physically colocated. A review of the distance simulation literature showed that heterogeneity in many areas (including nomenclature, methodology, and outcomes) limited the ability to identify best practice. In April 2020, the Healthcare Distance Simulation Collaboration was formed with the goal of addressing these issues. The aim of this study was to identify future research priorities in the field of distance simulation using data derived from this summit. METHODS: This study analyzed textual data gathered during the consensus process conducted at the inaugural Healthcare Distance Simulation Summit to explore participant perceptions of the most pressing research questions regarding distance simulation. Participants discussed education and patient safety standards, simulation facilitators and barriers, and research priorities. Data were qualitatively analyzed using an explicitly constructivist thematic analysis approach, resulting in the creation of a theoretical framework. RESULTS: Our sample included 302 participants who represented 29 countries. We identified 42 codes clustered within 4 themes concerning key areas in which further research into distance simulation is needed: (1) safety and acceptability, (2) educational/foundational considerations, (3) impact, and (4) areas of ongoing exploration. Within each theme, pertinent research questions were identified and categorized. CONCLUSIONS: Distance simulation presents several challenges and opportunities. Research around best practices, including educational foundation and psychological safety, are especially important as is the need to determine outcomes and long-term effects of this emerging field.

Factors of Engagement in Synchronous Online Learning Conversations and Distance Debriefing: A Realist Synthesis Review.

SUMMARY STATEMENT: The COVID-19 pandemic propelled remote simulation and online distance debriefings. Like in-person debriefings, faculty seek to facilitate effective reflective discourse. The online learning environment, however, presents challenges to learner engagement that differ considerably from in-person debriefing, yet little research exists in this area. In an effort to identify factors that influence debriefing engagement in the online environment, we conceptualized distance debriefings as complex social interactions and performed a realist review of the literature for evidence in the fields of online learning, healthcare simulation, instructional design, and other teaching and learning fields to see whether we might discern factors that influence engagement in online learning conversations that might inform online distance debriefing best practices. Eighteen articles were found through our search of 5 online databases (MEDLINE, CINAHL, ERIC, Google Scholar). We conducted iterative purposeful searching and continued to do so throughout the review to try to identify any additional studies that would contribute to our understanding. A thematic analysis of the findings of our included articles revealed indicators categorized using the community of inquiry framework, enabling us to understand and explain them in the context of online learning and propose their application to distance debriefing engagement. We also propose a new dimension to the framework: internal and external factors of engagement. Our findings demonstrate that online learning can positively influence engagement of learners if essential factors are implemented. These factors may inform recommendations for best practices toward learner engagement during healthcare simulation distance debriefing.

Teaching, coaching, or debriefing With Good Judgment: a roadmap for implementing "With Good Judgment" across the SimZones.

Simulation-based learning occurs in multiple contexts, and one teaching style cannot adequately cover the needs at each learning level. For example, reflective debriefing, often used following a complex simulation case, is not what is needed when learning new skills. When to use which facilitation style is a question that educators often overlook or struggle to determine. SimZones is a framework used to clarify the multiple contexts in simulation. This framework, combined with elements of Debriefing With Good Judgment, can help educators match the appropriate facilitation style with learner needs and learning context. We have distilled the core elements of the "with good judgment" approach to debriefing and applied them to the SimZones framework to guide educators with (1) what type of learning can be expected with each learning context, (2) what behaviors and activities can be expected of the learners in each learning context, (3) what instructional strategies are most effectively used at each stage, and (4) what are the implications for the teacher-learner relationship.

Organizational Factors That Promote Error Reporting in Healthcare: A Scoping Review.

GOAL: The overarching aim of this systematic review was to offer guidelines for organizations and healthcare providers to create psychological safety in error reporting. The authors wanted to identify organizational factors that promote psychological safety for error reporting and identify gaps in the literature to explore innovative avenues for future research. METHODS: The authors conducted an online search of peer-reviewed articles that contain organizational processes promoting or preventing error reporting. The search yielded 420 articles published from 2015 to 2021. From this set, 52 full-text articles were assessed for eligibility. Data from 29 articles were evaluated for quality using Joanna Briggs Institute critical appraisal tools. PRINCIPAL FINDINGS: We present a narrative review of the 29 studies that reported factors either promoting error reporting or serving as barriers. We also present our findings in tables to highlight the most frequently reported themes. Our findings reveal that many healthcare organizations work at opposite ends of the process continuum to achieve the same goals. Finally, our results highlight the need to explore cultural differences and personal biases among both healthcare leaders and clinicians. APPLICATIONS TO PRACTICE: The findings underscore the need for a deeper dive into understanding error reporting from the perspective of individual characteristics and organizational interests toward increasing psychological safety in healthcare teams and the workplace to strengthen patient safety.

Perspectives of engagement in distance debriefings.

BACKGROUND: The COVID-19 pandemic propelled remote simulation and online distance debriefings. Like in-person debriefings, educators seek to facilitate reflective learning conversations, yet, in the online setting, educators face challenges to learner engagement that differ considerably from in-person debriefing. METHODS: We performed a thematic analysis of fourteen semi-structured interviews conducted with fourteen participants who had experience with virtual debriefing as an educator or as a learner. We explored the experiences and perceptions of both educators and learners to provide a more in-depth understanding of the factors that influence engagement in online distance debriefing. RESULTS: Our study identified the challenges online distance debriefing poses for educators and learners. We found ten themes that support the Community of Inquiry (CoI) theoretical framework and provided additional considerations related to internal and external factors of engagement, including the influence of the simulation, false engagement, and self-presence. CONCLUSIONS: We believe these findings can inform the design and facilitation of online debriefings to help provide educators with guidance and innovative solutions to best engage their learners in the challenging online environment.

A Tribute to Chad Epps: A Mentor, Educator, Leader, Collaborator, and Friend.

SUMMARY STATEMENT: Dr Chad Epps' journey in healthcare simulation touched countless lives in his role as a mentor, educator, leader, collaborator, and friend. Here, we highlight Chad's lasting impact upon which we all stand today.

Cultural Considerations in Debriefing.

SUMMARY STATEMENT: Culture influences how we communicate, teach, and learn. Debriefings are laden with cultural influences. Without attention to cultural considerations, accepted debriefing techniques might not reach the desired outcome and, in certain cultures, may even harm teacher-learner relationships. We explore cultural considerations in healthcare simulation debriefing and offer guidance for debriefers to gain awareness of potential cultural biases.

Closing the gap: a call for a common blueprint for remote distance telesimulation.

The physical requirements mandated by the COVID-19 pandemic have presented a challenge and an opportunity for simulation educators. Although there were already examples of simulation being delivered at a distance, the pandemic forced this technique into the mainstream. With any new discipline, it is important for the community to agree on vocabulary, methods and reporting guidelines. This editorial is a call to action for the simulation community to start this process so that we can best describe and use this technique.

Cultural considerations in debriefing: a systematic review of the literature.

Background: Conversations are influenced by cultural perceptions, beliefs and values. Debriefing is a learning conversation. Without cross-cultural engagement or culturally relevant teaching, learning may be compromised and may result in an outcome opposite of that intended. Objective: This systematic review explores cultural considerations in healthcare simulation debriefing. We sought to explore findings that could help debriefers create culturally responsive and inclusive debriefings. Study selection: Studies were included if they were peer-reviewed articles in any language and focused on healthcare simulation debriefing and global cultural considerations. Research study methods included qualitative, quantitative or both. The review included any health-related profession and level of learner. Findings: Three studies met the criteria. The purposes of the three studies were significantly different and did not directly study cultural considerations in debriefing. Conclusions: The learner-educator relationship is at risk and learning may be negatively impacted without addressing cultural awareness. More studies are needed to fully describe the effect of culture on successful debriefing.