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Simulation Learning

Evidence-informed information and resources for simulation-based education

Introduction

According to HSSOBP™, prebriefing is a process involving the preparation and briefing activities of a simulation-based experience. It refers to activities prior to the start of the simulation scenario, including those related to both preparation and briefing (McDermott et al., 2021). 

Facilitators should use evidence-informed prebriefing techniques. Facilitators can help to establish a psychologically safe learning environment in the prebrief by:   

  1. Positioning learners into a shared mental model and preparing them for the educational aspect of the simulation-based experience (preparation).  
  2. Discussing important ground rules and logistical aspects related to the simulation-based experience (briefing).  

Providing a psychologically safe environment during the prebrief creates a more effective context for learning in simulation. It allows learners to engage in both the simulation and debriefs, despite potential unrealistic aspects of the scenario. Creating a safe environment also:

  • gives learners protection from threats to their professional identity
  • encourages them to take risks
  • supports frank discussion of mistakes without fear

(Rudolph, Raemer, & Simon, 2014).  

The following article offers more information about the 'safe container' concept:

Note: Nova Scotia Health staff and physicians can submit a document delivery request for a copy of this article.

Standards of Best Practice

The HSSOBP™ describes both the preparation and briefing components of prebriefing.

  • During the preparation phase, learners are provided with materials to familiarize them with the content and scenario objectives before simulation.
  • The briefing phase:
    • contributes to psychological safety
    • introduces learners to the simulated environment
    • communicates essential information about expectations, roles of participants, schedule, and logistics.  

General criteria necessary to meet the Prebriefing Standard  

  1. The simulationist should be knowledgeable about the scenario and competent in concepts related to prebriefing.  
  2. Prebriefing should be developed according to the purpose and learning objectives of the simulation-based experience.  
  3. The experience and knowledge level of the simulation learner should be considered when planning the prebriefing.

(McDermott et al., 2021).

©2021 INACSL. Used with permission.

 

Elements of the Prebrief

Prebriefing can effectively prepare learners for simulation, reduce learner anxiety, and promote psychological safety. Intentional design and thoughtful delivery of the prebrief enhances learning by promoting a psychologically safe environment for the simulation activity (Somerville et al., 2023). Experts recommend that novice facilitators use a script when prebriefing. The depth and length of the prebrief should be modified based on factors such as:

  • the experience level of learner(s)
  • the learner(s) experience with simulation
  • the learning objectives
  • the environment

Psychological safety is a key factor when designing and conducting a prebriefing session. It should inform all elements of the prebrief. Although there is no clear consensus on how to categorize essential components of a prebrief, it is generally agreed that the following elements are required:

  • Roles and Responsibilities
  • Logistics
  • Objectives
  • Orientation to the Environment
  • Confidentiality
  • Fiction Contract

Select the tabs above for more information.

It is important that both participants and facilitators have a clear understanding of what is expected of them. For each role, define expectations for each phase of the simulation process (prebrief, simulation, debriefing). Rudolph and colleagues (2014) indicate that learners must see consistency in the facilitators’ actions and words if they are to feel supported within the ‘safe container’ of learning.

Facilitators should introduce the concept of The Basic Assumption™. This is a commitment from facilitator(s) to learners that they will be treated in a respectful manner without judgment throughout the simulation, thus promoting a safe learning environment (Rudolph et al., 2014). We recommend printing and displaying The Basic Assumption™ in simulation spaces, as well as verbally stating it during the prebrief. The Basic Assumption™ is often reiterated again at the start of the debrief.

Here is an example of The Basic Assumption™ signage:  

 

Facilitators should inform participants of logistical details surrounding the simulated activity. This is especially important for adult learning and may include:

  • an agenda
  • the length of the scenario(s)
  • break times
  • location of bathroom 

Participants require clear learning objectives that link the simulation to the objectives and relevant clinical practice.

Note: It is not always necessary, or advantageous, to provide all the learning objectives in the prebrief. However, at a minimum, participants should have a general understanding of why a simulation is occurring.  

Participants need orientation to both the simulation space and equipment. The depth of orientation to equipment will depend on the complexity of the equipment used and the participants' experience with the space/equipment. Consider building in time for participants to ask questions about the equipment. 

Remind participants to maintain confidentiality of scenario content and performance. Confidentiality practices are required to meet the Healthcare Simulation Standards of Best Practice™ Professional Integrity standards (Bowler et al., 2021). Include a confidentiality clause during prebriefing and revisit it during debriefing. Address limits to confidentiality.  

A fiction contract is a voluntary agreement between facilitators and participants that:

  • acknowledges that simulation is not real
  • promises that the facilitator has attempted to make the simulation activity as real as possible within the limitations of the environment
  • asks the participants to suspend of disbelief during the simulation.

(Loice, et al., 2020)

The facilitator may include specific simulator/mannikin limitations and inform the learners of how those limitations will be overcome. Within the fiction contract, participants are asked to engage as if the simulation were a real-life patient encounter. A fiction contract helps to:

  • enhance realism 
  • improve immersion of learners into the simulation
  • minimize blame of the environment/equipment
  • improve the learner’s ability to transfer their learning into a practice setting  

(Loice, et al., 2020)

Listen to this podcast outlining the prebriefing process: 

Integrating EDI in Prebriefing

As the foundation of the simulation experience, the prebrief should be prepared based on principles of equity, diversity, and inclusion. A commitment to the principles of EDI by all facilitators, learners, and participants helps to create a safe learning environment.

This means:

  • Use inclusive language 
  • Provide a personalized land acknowledgement 
  • Accommodate participants needs (such as accessible materials, environments, and activities)
  • Be receptive to feedback  

Emphasis on confidentiality is particularly important when discussing challenging topics such as biases, racism, and sexism. 

Where relevant to the scenario, it may be valuable to highlight contextual information about the patient's background in the introduction to the scenario, such as:

  • their cultural traditions
  • their religious beliefs
  • variables associated with the patient's perspectives on their part in the healthcare process.

This practice may guide the learner to value personal perspectives (Alrimawi et al., 2024).

You may introduce the concept of a safe word or pause for the learner to use to stop the scenario if they feel unsafe or distressed. It may be helpful to make participants aware of available resources should they experience distress during the activity.  

Putting it All Together

A structured prebrief, using a checklist or concept map, significantly enhances learners’ competency performance, clinical judgment, and perceptions of prebriefing. It:

  • enables learners to reflect on their previous experiences and anticipate the plan of management more effectively (Darwish et al., 2023).
  • provides facilitators a framework to use, and the ability to modify their approach to facilitating a simulation as needed. 

The outline below, developed by Somerville and colleagues (2023), provides 12 tips for designing, implementing, and steering the prebrief to promote psychological safety in simulation-based education.

Figure 1. Twelve tips for designing, implementing, and steering the pre-brief to promote psychological safety in simulation-based education by  Susan Geraldine Somerville, Neil Malcolm Harrison, & Steven Anthony Lewis, is licensed CC BY-NC-ND.

If you’d like to read more on this, the full article can be found here:

Additional examples of prebriefing checklists can be found here: 

References

Alrimawi, I., El-Banna, M. M., O'Reilly, C., & Muhammad, K. (2024). Integrating diversity, equity, and inclusion in nursing simulation and clinical. Teaching and Learning in Nursing, 19(2), e439-e443. https://doi.org/10.1016/j.teln.2024.01.010

Bowler, F., Klein, M. & Wilford, A. INACSL Standards Committee (2021). Healthcare Simulation Standards of Best Practice™ professional integrity. Clinical Simulation in Nursing, 58, 45-48. https://doi.org/10.1016/j.ecns.2021.08.014

Darwish, E., Jaradat, A., Ibrahim, N., Ghalib, K., Khonji, S., Gutierrez, R., & Garadah, T. (2023). The effect of a structured pre-briefing simulation session on medical students’ competency. Jordan Medical Journal, 57(3). https://doi.org/10.35516/jmj.v57i3.1680

International Nursing Association for Clinical Simulation & Learning. (2021). Prebriefing: Preparation and Briefing [Infographic]. https://www.inacsl.org/simfographics. Used with permission.

McDermott, D. S., Ludlow, J., Horsley, E., & Meakim, C. INACSL Standards Committee. (2021). Healthcare Simulation Standards of Best Practice™ prebriefing: Preparation and briefing. Clinical Simulation in Nursing, 58, 9-13. https://doi.org/10.1016/j.ecns.2021.08.008

Purdy, E., Borchert, L., El-Bitar, A., Isaacson, W., Bills, L., & Brazil, V. (2022). Taking simulation out of its “safe container”—exploring the bidirectional impacts of psychological safety and simulation in an emergency department. Advances in Simulation, 7(5) https://doi.org/10.1186/s41077-022-00201-8

Rudolph, J. W., Raemer, D. B., & Simon, R. (2014). Establishing a safe container for learning in simulation: The role of the presimulation briefing. Simulation in Healthcare, 9(6), 339-349. https://doi.org/10.1097/SIH.0000000000000047

Rutherford-Hemming, T., Lioce, L., & Breymier, T. (2019). Guidelines and essential elements for prebriefing. Simulation in Healthcare: Journal of the Society for Simulation in Healthcare, 14(6), 409–414. https://doi.org/10.1097/SIH.0000000000000403

Somerville, S. G., Harrison, N. M., & Lewis, S. A. (2023). Twelve tips for the pre-brief to promote psychological safety in simulation-based education. Medical Teacher, 45(12), 1349-1356. https://doi.org/10.1080/0142159X.2023.2214305