BACKGROUND:Routine clinical debriefings (RCDs) have been shown to improve communication, team reflexivity, and safety in clinical settings. When combined with incident reports (IRs), RCDs offer a potential tool for enhancing quality improvement frameworks. This study aimed to identify and compare healthcare safety-related information captured through RCDs and IRs in a Belgian emergency department operating across two distinct facilities. METHODS:This study employed a quasi-mixed-method design with a monostrand conversion approach. Information was collected from 90 RCDs and 263 IRs. Data were analyzed using two frameworks: the World Health Organization's Incident Report Classification Grid and the Debriefing and Organizational Lessons Learned Grid. RESULTS:The findings revealed significant differences in the types of information captured by RCDs and IRs. RCDs predominantly highlighted teamwork, internal organization, and procedural issues, while IRs focused more on care processes, patient concerns, and patient flow. These complementary insights demonstrate the value of integrating RCDs and IRs to create a comprehensive understanding of patient and clinician safety. CONCLUSIONS:This study highlights the complementary nature of RCDs and IRs in addressing healthcare safety. RCDs foster team reflexivity and promote open discussions about systemic challenges, directly improving team cohesion, resilience, and learning. Combining RCDs and IRs provides actionable insights for enhancing safety and driving organizational improvements.

Teaching and learning debriefing and feedback skills—especially to a level of mastery—is challenging without an agreed-upon standard. There are a number of rating scales and rubrics to identify and evaluate debriefing and feedback skills that focus on an entire feedback or debriefing conversation. However, there is no rubric to assess and provide feedback on one of these conversations' most widely used microskills, the Advocacy-Inquiry technique. This study aimed to develop and preliminarily test the Advocacy-Inquiry Rubric (AIR)—a tool designed to support the teaching, coaching, and assessment of Advocacy-Inquiry, a widely used yet challenging debriefing microskill—through an international expert consensus process. Using a four-round Delphi process, we achieved expert consensus on the behavioral markers of effective and ineffective Advocacy-Inquiry techniques. Thirty-nine experts from 13 countries identified and refined a set of key behavioral anchors for each of Advocacy-Inquiry’s five elements: Preview, Observation, Point of View, Inquiry, and Listen. These descriptors were embedded first in a seven-point numeric Behaviorally Anchored Rating Scale, then in a three-point emoji-based version, and finally in a teaching and learning version. The AIR underwent two rounds of usability testing and inter-rater testing of the emoji version. Using an interpretation-use argument approach, evidence was collected for AIR’s validity across scoring, generalization, extrapolation, and implication. The Delphi process established descriptors for each element of Advocacy-Inquiry, categorized by proficiency level (beginner to advanced). Usability testing enhanced the AIR’s graphic layout to support both numeric ratings and formative feedback. The AIR was adapted into three tailored versions: a numeric AIR for detailed evaluation and progress tracking, an emoji AIR for peer assessment, and a teaching and learning AIR. Evidence for validity was assessed, highlighting both strengths and gaps. AIR is an empirical rubric based on expert-derived criteria to support teaching, coaching, and assessing Advocacy-Inquiry microskills. The AIR offers a structured framework for self-, peer-, and mentor-led feedback and assessment to enhance a core skill of facilitators. By anchoring assessments in clear behavioral descriptors, the AIR aims to improve the quality of feedback and debriefing conversations. Future work should focus on rater training, reliability testing, and exploring the AIR’s impact on real-world outcomes.

Abstract Background Use of the Debriefing Assessment for Simulation in Healthcare (DASH©) would be beneficial for novice debriefers with less or no formal training in debriefing. However, the DASH translated into Korean and tested for psychometrics is not yet available. Thus, this study was to develop a Korean version of the DASH student version (SV) and test its reliability and validity among baccalaureate nursing students in Korea. Methods The participants were 99 baccalaureate nursing students. Content validity using content validity index (CVI), construct validity using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), and internal consistency using Cronbach’s alpha coefficient were assessed. Results Both Item-CVIs and Scale-CVI were acceptable. EFA supported the unidimensional latent structure of Korean DASH-SV and results of CFA indicated 6 items converged within the extracted factor, significantly contributing to the factor (p ≤ .05). Items were internally consistent (Cronbach’s α = 0.82). Conclusion The Korean version of the DASH-SV is arguably a valid and reliable measure of instructor behaviors that could improve faculty debriefing and student learning in the long term.

BACKGROUND:Debriefing Assessment for Simulation in Healthcare (DASH©) is an instrument to assist in developing and evaluating debriefing skills. The objectives of this study were to translate the DASH from English to Portuguese and to conduct a cross-cultural adaptation of this translated instrument for Portugal and Brazil.METHODS:A forward translation of the DASH score sheets and Rater's Handbook was accomplished and reviewed by authors from both Portuguese-speaking countries to reach the consensus harmonized version. A backward translation was reviewed by the original authors and discussed with the authors to produce the approved harmonized translation. This was then tested through a questionnaire to assess clarity, comprehensiveness, appropriateness, and cultural relevance among 10 simulation specialists from Portugal and Brazil.RESULTS:During the forward translation, 19 discrepancies were detected in the Portuguese DASH. After backward translation, 7 discrepancies were discussed and harmonized. All 10 simulation specialists from both countries reviewed the harmonized translation and made 70 suggestions, 64 of which were incorporated in the instrument after discussion among authors.CONCLUSIONS:The translated DASH has undergone translation to Portuguese and a cross-cultural adaptation across Portugal and Brazil. It may be used to assess debriefings in healthcare settings in these countries.

We read with interest the studies exploring the applicability and effectiveness of virtual simulation on nursing students ( Fogg et al., 2020 Fogg N. Kubin L. Wilson C.E. Trinka M. Using virtual simulation to develop clinical judgment in undergraduate nursing students. Clinical Simulation in Nursing. 2020; 48: 55-58https://doi.org/10.1016/j.ecns.2020.08.010 Abstract Full Text Full Text PDF Scopus (15) Google Scholar ; Kang et al., 2020 Kang S.J. Hong C.M. Lee H. The impact of virtual simulation on critical thinking and self-directed learning ability of nursing students. Clinical Simulation in Nursing. 2020; 49: 66-72https://doi.org/10.1016/j.ecns.2020.05.008 Abstract Full Text Full Text PDF Scopus (17) Google Scholar ). Although virtual simulation is a concept that includes a wide variety of technology-assisted distance learning methods ( Lopreiato, 2016 Lopreiato J.O. Healthcare simulation dictionary. Agency for Healthcare Research and Quality. Publication No. 16(17)-0043, Rockville, MD2016 Google Scholar ), we have not found a fully articulated approach for the best educational design to help attain intended learning outcomes.

Introduction Debriefing Assessment for Simulation in Healthcare (DASH) is an instrument to assist in developing and evaluating faculty debriefing and instructional skills that, in the context of trained raters, yields reliable data and internal consistency. Support for its validity is grounded in both its content and the scores arising from its use. The utilization of this and other assessment tools, guidelines, and protocols is expanding internationally, but most of them are available only in English and there is not a single established methodology for translation. The objectives of this study were to demonstrate a translation technique and conduct a linguistic validation of the translation of the DASH from English to Spanish and to demonstrate and conduct a cultural validation across 8 Spanish-speaking countries. Methods A forward translation and review of the DASH score sheets and Rater's Handbook defined the consensus harmonized version. A backward translation was reviewed by the original authors and discussed with the translators to produce the approved harmonized version. This was then tested through a questionnaire to assess clarity, comprehensiveness, appropriateness, and cultural relevance among 5 monolingual subjects from 8 Spanish-speaking countries. Results During the forward translation, 16 discrepancies were detected in the Spanish DASH. Sixty-two participants were sent the Spanish cultural questionnaire and 48% responded. A total of 82 different interpretations and 57 extra recommendations (42% terms, 16% concepts, and 42% syntax) were made. Twenty-seven percent of them were applied. Conclusions The translated DASH has undergone a linguistic validation into Spanish, and a cultural validation across 8 Spanish-speaking countries. It may be used to assess debriefings in healthcare settings in these countries. The methodology used is applicable for translating and assessing a cross-cultural validation of assessment instruments.

Revisiones recientes de la literatura de simulación resaltan el papel crítico del informe (debriefing) en el proceso de aprendizaje.Por ello, ha aumentado el número de profesionales de la salud y otras disciplinas que se han capacitado como educadores para la realización del mismo.Sin embargo, a medida que aumenta el número y alcance de las actividades realizadas, no siempre es posible encontrar educadores que a la vez sean especialistas en el área específica de entrenamiento.Por ello, es común realizar los debriefings en colaboración con expertos en contenidos de diferentes áreas, que con frecuencia no tienen experiencia previa con educación basada en simulación.No se ha encontrado ninguna referencia específica a las oportunidades y retos propios de esta interacción.Por ello, el objetivo fue elaborar una guía para facilitar el debriefing entre educadores y expertos en contenidos que: 1) describa las ventajas de este tipo de colaboración, 2) discuta los desafíos comunes encontrados y 3) proponga herramientas prácticas para superar los desafíos específicos y, además, sugerir direcciones futuras para la investigación. AbstrActRecent simulation literature reviews highlight the critical role of debriefing in the learning process.As a consequence, there has been an increase in the number of health and allied professionals that have been trained to conduct debriefings.However, as the number and scope of the activities increase, it is not always possible to find expert debriefers who are also experts in the specific content area.Therefore, it is increasingly common for educators to collaborate with content experts in various fields in healthcare, who often have no previous experience with simulation-based education.No references to the particular opportunities and challenges of this interaction has been found.Therefore, the objective was to propose a guide to: 1) describe the advantages of this type of collaboration, 2) discuss common challenges and 3) overcome specific challenges; also, to suggest future directions for research.

View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Nursing education programs face an increasing challenge: how to help students transition to practice as the number of clinical placements shrink and the costs of placements rise. Many nursing schools are looking to simulation-based education to help bridge this gap (Fey and Jenkins, 2015Fey M.K. Jenkins L.S. Debriefing practices in nursing education programs: Results from a national study.Nursing Education Perspectives. 2015; 36: 361-366Google Scholar, Rizzolo, 2013Rizzolo M.A. Clinical simulations in nursing education: Advanced concepts, trends, and opportunities.in: Jeffries P. History and evolution of simulations: from oranges to avatars. Lippencott, Williams and Wilkins, Philadelphia, PA2013Google Scholar). When simulation complements or substitutes for traditional clinical placements, the quality of educator's debriefing skills is a key factor to leverage the power of simulation (Hayden et al., 2014Hayden J.K. Smiley R.A. Alexander M. Kardong-Edgren S. Jeffries P.R. The NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education.Journal of Nursing Regulation. 2014; 5: S1-S66Google Scholar). We focus on a key driver of nursing educator debriefing excellence: using a debriefing standard to guide skills building and assess faculty competencies. How does one “connect the dots” from educator debriefing standards to student clinical practice? Standards and guidelines for high-impact debriefing create a pathway to improve trainees' hands-on, applied learning using simulation-based education. Well-designed hands-on, simulation-based education, in turn, standardizes and accelerates acquisition of applied skills, instead of relying on time and chance to ensure that trainees are exposed to needed material (Gordon, 2012Gordon J.A. As accessible as a book on a library shelf: The imperative of routine simulation in modern health care.Chest. 2012; 141: 12-16https://doi.org/10.1378/chest.11-0571Google Scholar, Issenberg et al., 2005Issenberg B.S. McGaghie W.M. Petrusa E.R. Gordon D.L. Scalese R.J. Features and uses of high-fidelity medical simulation that lead to effective learning: A BEME systematic review.Medical Teacher. 2005; 27: 10-28Google Scholar, McGaghie et al., 2014McGaghie W.C. Issenberg S.B. Barsuk J.H. Wayne D.B. A critical review of simulation-based mastery learning with translational outcomes.Medical Education. 2014; 48: 375-385https://doi.org/10.1111/medu.12391Google Scholar, McGaghie et al., 2010McGaghie W.C. Issenberg S.B. Petrusa E.R. Scalese R.J. A critical review of simulation-based medical education research: 2003-2009.Medical Education. 2010; 44: 50-63https://doi.org/10.1111/j.1365-2923.2009.03547.xGoogle Scholar). Simulation plus debriefing provides standardized exposure with accelerated learning to systematically bridge the gap from theory and didactics to practice. While simulation itself often seems like “the main event,” postsimulation debriefing plays a crucial role in helping learners sustain good or improve weak performance (Dreifuerst, 2009Dreifuerst K.T. The essentials of debriefing in simulation learning: A concept analysis.Nursing Education Perspectives. 2009; 30: 109-114Google Scholar, Eppich et al., 2015Eppich W.J. Hunt E.A. Duval-Arnould J.M. Siddall V.J. Cheng A. Structuring feedback and debriefing to achieve mastery learning goals.Academic Medicine. 2015; 90: 1501-1508https://doi.org/10.1097/ACM.0000000000000934Google Scholar, Hunt et al., 2014Hunt E. Duval-Arnould J.M. Nelson-McMillan K. Bradshaw J. Diener-West M. Perretta J. Shilkofski N. Pediatric resident skills improve after “rapid cycle deliberate practice” training.Resuscitation. 2014; 85: 945-951Google Scholar). Importantly, successful debriefing not only helps transform learners' actions but helps learners transform perspectives and cognitive frameworks (Morse, 2015Morse K.J. Structured model of debriefing on perspective transformation for NP students.Clinical Simulation in Nursing. 2015; 11: 172-179http://dx.doi.org/10.1016/j.ecns.2015.01.001Google Scholar, Rudolph et al., 2006Rudolph J.W. Simon R. Dufresne R.L. Raemer D.B. There's no such thing as a “non-judgmental” debriefing: A theory and method for debriefing with good judgment.Simulation in Healthcare. 2006; 1: 49-55Google Scholar). Transforming existing assumptions, knowledge, and other cognitive frames is what helps nursing students provide improved patient care (Kolb, 1984Kolb D.A. Experiential learning: Experience as the source of learning and development. Prentice-Hall, Englewood Cliffs, NJ1984Google Scholar, Palaganas et al., 2016Palaganas J. Fey M. Simon R. Structured debriefing in simulation-based education.Advanced Critical Care. 2016; 27: 78-85Google Scholar, Schön, 1987Schön D. Educating the reflective practitioner: Toward a new design for teaching and learning in the professions. Jossey-Bass, San Francisco1987Google Scholar). In contrast, poorly executed debriefings—whether in simulation, or across the curriculum—at best, leave learners' thinking and future actions unchanged, and, at worst, can demoralize learners or deprive them of learning (Archer, 2010Archer J.C. State of the science in health professional education: Effective feedback.Medical Education. 2010; 44: 101-108https://doi.org/10.1111/j.1365-2923.2009.03546.xGoogle Scholar, Baron, 1988Baron R.A. Negative effects of destructive criticism: Impact on conflict, self-efficacy, and task performance.Journal of Applied Psychology. 1988; 73: 199-207Google Scholar). To ensure that simulation is a robust substitute for clinical placements, educator competence in debriefing is important; moreover, educator excellence can be transformational for learners. Three recent policy statements underscore the quality of debriefing as a crucial factor in the impact of simulation-based nursing education. A National Council of State Boards of Nursing (NCSBN) study (Hayden et al., 2014Hayden J.K. Smiley R.A. Alexander M. Kardong-Edgren S. Jeffries P.R. The NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education.Journal of Nursing Regulation. 2014; 5: S1-S66Google Scholar), a National League of Nursing vision statement on debriefing across the curriculum (National League for Nursing (NLN) Board of Governors, 2015National League for Nursing (NLN) Board of GovernorsDebriefing across the curriculum.2015Google Scholar), and standards set by the International Nursing Association for Clinical Simulation and Learning (INACSL; Decker et al., 2013Decker S. Fey M. Sideras S. Caballero S. Boese T. Franklin A.E. Borum J.C. Standards of best practice: Simulation standard VI: The debriefing process.Clinical Simulation in Nursing. 2013; 9: S26-S29Google Scholar) all draw connections between well-structured, theory-based debriefing and learning outcomes. While there is increasing incentive to enhance debriefing in simulation-based nursing education, two barriers make it difficult to develop a cadre of skilled debriefers: knowledge around what makes a debriefing “good” and how to meet these standards. One barrier is balancing the various and sometimes competing needs that a debriefing entails. Instructors ask themselves: Is debriefing feedback or coaching? What is the role of this discussion? How much, if any, didactic teaching should take place? Should it be instructor-guided or primarily learner-centered? In simulation, learners are typically expected to demonstrate a number of clinical skills and to make a wider range of nursing decisions. In the context of multiple skills and decisions demonstrated or not demonstrated, what objectives are important to cover? Is debriefing undergraduates and preclinical students different from graduate and practicing nurses? While guidance on these questions is emerging (Eppich and Cheng, 2015Eppich W.J. Cheng A. Promoting excellence and reflective learning in simulation (PEARLS): Development and rationale for a blended approach to health care simulation debriefing.Simulation in Healthcare. 2015; 10: 106-115https://doi.org/10.1097/SIH.0000000000000072Google Scholar, Jeffries et al., 2015Jeffries P.R. Dreifuerst K.T. Kardong-Edgren S. Hayden J. Faculty development when initiating simulation programs: Lessons learned from the National Simulation Study.Journal of Nursing Regulation. 2015; 5: 17-23Google Scholar), it has been difficult for individual instructors or their simulation programs to know what knowledge, skills, and attitudes should be developed to enhance the capacity of learning in debriefing (Cheng et al., 2015Cheng A. Grant V. Dieckmann P. Arora S. Robinson T. Eppich W. Faculty development for simulation programs: Five issues for the future of debriefing training.Simulation in Healthcare. 2015; 10: 217-222https://doi.org/10.1097/SIH.0000000000000090Google Scholar). The second barrier is uncertainty on how specifically to meet standards of debriefing, such as those recently published by the INACSL (Decker et al., 2013Decker S. Fey M. Sideras S. Caballero S. Boese T. Franklin A.E. Borum J.C. Standards of best practice: Simulation standard VI: The debriefing process.Clinical Simulation in Nursing. 2013; 9: S26-S29Google Scholar). It is challenging for programs to focus simulation-based educator development efforts without specific, actionable examples of what effective debriefing structure, behaviors, phrasing might be (Fey and Jenkins, 2015Fey M.K. Jenkins L.S. Debriefing practices in nursing education programs: Results from a national study.Nursing Education Perspectives. 2015; 36: 361-366Google Scholar). While general standards are very helpful, aiming for specific target behaviors is a key component of deliberate practice (Ericsson et al., 1993Ericsson K.A. Krampe R.T. Tesch-Romer C. The role of deliberate practice in the acquisition of expert performa.Psychological Review. 1993; 100: 363-406Google Scholar, Hunt et al., 2014Hunt E. Duval-Arnould J.M. Nelson-McMillan K. Bradshaw J. Diener-West M. Perretta J. Shilkofski N. Pediatric resident skills improve after “rapid cycle deliberate practice” training.Resuscitation. 2014; 85: 945-951Google Scholar) needed to achieve competence, excellence, or mastery of any skill, including debriefing. We believe that systematic, valid, and reliable standards for developing, critiquing, and assessing debriefing skills can overcome confusion about “what is debriefing, anyway?” and set concrete debriefing skill targets which an educator can work toward. The first and senior author (J.R., R.S.) have developed one such standard called the Debriefing Assessment for Simulation in Healthcare (DASH; Brett-Fleegler et al., 2012Brett-Fleegler M. Rudolph J. Eppich W. Monuteaux M. Fleegler E. Cheng A. Simon R. Debriefing assessment for simulation in healthcare: Development and psychometric properties.Simulation in Healthcare. 2012; 7: 288-294https://doi.org/10.1097/SIH.0b013e3182620228Google Scholar). The DASH was used in the recent NCSBN study of simulation efficacy (Hayden et al., 2014Hayden J.K. Smiley R.A. Alexander M. Kardong-Edgren S. Jeffries P.R. The NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education.Journal of Nursing Regulation. 2014; 5: S1-S66Google Scholar) and many other studies. The DASH is a behaviorally anchored rating scale that can provide:1)A research and theory-based standard to assess educator competence in debriefing that can be applied to any style of debriefing.2)A developmental tool to guide debriefing skill acquisition via self- and peer-assessment. How, specifically, can the DASH help simulation educators assess or develop their debriefing skills? The DASH enumerates strong and weak debriefing practices. Different versions of the DASH allow educators to self-assess, provide peer-to-peer feedback, expert assessments, or allow for student assessments of debriefings. Because the DASH highlights different elements of debriefing, peer groups of educators or formal educator development programs can select elements of debriefing to work on. Here are five examples of the DASH being used to guide or assess debriefing practice in a way that allows faculty to support practice readiness in their students: The DASH is used at the University of Maryland School of Nursing as part of a comprehensive development plan for simulation faculty. During the orientation period, new simulation faculty are familiarized with the elements and dimensions of the DASH in conjunction with attending a debriefing workshop and work with an experienced mentor. During the remainder of the orientation period, the DASH is used to provide formative feedback to new faculty until they are ready to debrief independently. Beyond the orientation period, the DASH is used to provide formative feedback to all simulation faculty. Each faculty member videotapes a debriefing at least once per year. Several experienced simulation faculty then review the video with that person and use the DASH to provide formative feedback.Table 1DASH Elements and DimensionsElementDimensions1. Establishes an engaging learning environment (prebriefing).•Clarifies course objectives, environment, confidentiality, roles, and expectations.•Establishes a “fiction contract” with participants.•Attends to logistical details.•Conveys a commitment to respecting learners and understanding their perspective.2. Maintains an engaging learning environment.•Clarifies debriefing objectives, roles, and expectations.•Helps participants engage in a limited-realism context.•Conveys respect for learners and concern for their psychological safety.3. Structures the debriefing in an organized way.•Encourages learners to express their reactions and, if needed, orients them to what happened in the simulation, near the beginning.•Guides analysis of the learners' performance during the middle of the session.•Collaborates with participants to summarize learning from the session near the end.4. Provokes engaging discussions.•Uses concrete examples and outcomes as the basis for inquiry and discussion.•Reveals own reasoning and judgments.•Facilitates discussion through verbal and nonverbal techniques.•Uses video, replay, and review devices (if available).•Recognizes and manages the upset participant.5. Identifies and explores performance gaps.•Provides feedback on performance.•Explores the source of the performance gap.6. Helps learners achieve or sustain good future performance.•Helps close the performance gap through discussion and teaching.•Demonstrates firm grasp of the subject.•Meets the important objectives of the session. Open table in a new tab Since simulation-based learning activities are resource and educator intensive, they need to be used wisely. As the former director of the acute care nurse practitioner program at Drexel University School of Nursing and Health Professions, I realized that one potent focus of such activities is “shaking up” and transforming taken-for-granted thought patterns such as assumptions about scope of practice. In particular, I was interested in how to foster transformation of an experienced nurses' perspective to now include medical decision-making. To test this idea, I conducted a study using the DASH to examine the link between debriefing quality and changes in taken-for-granted thought patterns among nurse practitioner students (Morse, 2015Morse K.J. Structured model of debriefing on perspective transformation for NP students.Clinical Simulation in Nursing. 2015; 11: 172-179http://dx.doi.org/10.1016/j.ecns.2015.01.001Google Scholar). The findings showed that reflective debriefing can inspire students new to the nurse practitioner scope of practice. We found that well-structured, theory-based debriefing was able to transform experienced nurses' standard thinking to help them jump to new levels of practice. Using the DASH to study this process formally reinforced the value of scaffolding my colleagues and me to debrief in ways that create transformative learning experiences. As a past Chief Operations Officer of Loma Linda University Medical Simulation Center, I advocated the use of the DASH self- and peer-assessment to improve the quality of our program. In our weekly meetings, we randomly picked one simulation to review, including the debriefing. The DASH-trained staff used the DASH-Rater Version (DASH-RV) tool to assess the quality of our program via assessment of debriefers (in this case, trained educators who used our center). We filed the written assessment in the educators' mailboxes as a written feedback. If time permitted, we also provided verbal feedback to the educator using the tool. Examining and discussing recorded debriefings allowed program staff to learn and discuss factors for good debriefing by assessing themselves and others.Debriefing Assessment for Simulation in Healthcare (DASH) FactsGoal: To assess the quality of debriefings in health care simulation.Foundation: Drawn from theory and research on education, organizational behavior, psychology, and simulation in general; from international expert panel of debriefers; and from expert practical experience-based thousands of debriefings conducted by authors.Assessment type: Criterion referenced. The criteria describe domains of debriefing behaviors as six Elements each of which is defined by Dimensions that are further illustrated by example Behaviors.Use: Applicable to assess a variety of debriefing styles and settings.DASH family of instruments: DASH-Rater Version (for use by trained raters), DASH-Student Version (for use by students to assess their experience of an educator debriefing), and DASH-Instructor Version (for educator self-assessment). The DASH is available in German, French, Japanese with Spanish, Portuguese, and Arabic versions under development.DASH “Sibling” Instrument: Feedback Assessment for Clinical Education (FACE©; to assess feedback conversations in the clinical context).Availability: Additional information and access at www.harvardmedsim.org. Free with a Center for Medical Simulation copyright requirement to share any published use of the DASH via the DASH web page. Goal: To assess the quality of debriefings in health care simulation.Foundation: Drawn from theory and research on education, organizational behavior, psychology, and simulation in general; from international expert panel of debriefers; and from expert practical experience-based thousands of debriefings conducted by authors.Assessment type: Criterion referenced. The criteria describe domains of debriefing behaviors as six Elements each of which is defined by Dimensions that are further illustrated by example Behaviors.Use: Applicable to assess a variety of debriefing styles and settings.DASH family of instruments: DASH-Rater Version (for use by trained raters), DASH-Student Version (for use by students to assess their experience of an educator debriefing), and DASH-Instructor Version (for educator self-assessment). The DASH is available in German, French, Japanese with Spanish, Portuguese, and Arabic versions under development.DASH “Sibling” Instrument: Feedback Assessment for Clinical Education (FACE©; to assess feedback conversations in the clinical context).Availability: Additional information and access at www.harvardmedsim.org. Free with a Center for Medical Simulation copyright requirement to share any published use of the DASH via the DASH web page. Integrating debriefing across a curriculum enhances reflective practice skills in learners (National League for Nursing (NLN) Board of Governors, 2015National League for Nursing (NLN) Board of GovernorsDebriefing across the curriculum.2015Google Scholar). “Debriefing” in clinical learning environments often takes the form of reflective feedback conversations where educators and learners identify and explore performance gaps and develop new pathways to improved practice. The DASH provides anchors in providing high-quality feedback to learners. To develop a robust tool for assessing reflective feedback conversations in clinical learning environments, I used the DASH as a starting point. The result is the Feedback Assessment for Clinical Education (FACE; Onello, 2015Onello R. Assessing the quality of feedback during clinical learning: Development of the Feedback Assessment for Clinical Education (FACE). University of Maryland, Baltimore, MD, USA2015http://hdl.handle.net/10713/4617Google Scholar). Multidisciplinary research and international content experts informed the FACE structure and content. Parallel to the DASH, the FACE is a six-element, behaviorally anchored rating scale that applies principles of rigorous debriefing in the context of clinical feedback. It is both an assessment tool and a framework for educators to learn theory- and research-based, high-quality feedback behaviors.National Council of State Boards of Nursing Guidelines and International Nursing Association for Clinical Simulation and Learning Debriefing StandardGuidelines and regulations guiding debriefing qualityThe National Council of State Boards of Nursing (NCSBN) recently published findings from the landmark National Simulation Study (Hayden et al., 2014Hayden J.K. Smiley R.A. Alexander M. Kardong-Edgren S. Jeffries P.R. The NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education.Journal of Nursing Regulation. 2014; 5: S1-S66Google Scholar). Findings indicated that up to 50% of simulated learning can effectively be substituted for traditional clinical experiences, under conditions similar to those in the study. For further clarification, the NCSBN recently released Simulation Guidelines for Prelicensure Nursing Programs (Alexander et al., 2015Alexander M. Durham C.F. Hooper J.I. Jeffries P.R. Goldman N. Kardong-Edgren S. Tillman C. NCSBN simulation guidelines for prelicensure nursing programs.Journal of Nursing Regulation. 2015; 6: 39-42Google Scholar). In the guidelines, ensuring the competence of debriefing facilitators is addressed in several ways.Since the publication of the National Simulation Study, several state Boards of Nursing have made recommendations about the use of simulation. For example, Florida (http://floridasnursing.gov/latest-news/chapter-2014-92-laws-of-florida-became-effective-on-july-1-2014/) and Maryland now allow up to 50% substitution, without specific guidelines beyond those recommended by the NCSBN. The Arizona State Board of Nursing has published an Advisory Opinion regarding the use of simulation in RN programs. The Advisory Opinion recommends that facilitators have formal immersion training and competency assessment specific to their roles. Congruent with the NCSBN Guidelines, the Arizona Advisory Opinion recommends that programs using simulation in place of traditional clinical experiences adopt the International Nursing Association for Clinical Simulation and Learning (INACSL) Standards of Best Practice: Simulation.The INACSL Standard VI: The Debriefing Process, Criteria 1 states that debriefing should be “Facilitated by a Person(s) Competent in the Process of Debriefing” (Decker et al., 2013Decker S. Fey M. Sideras S. Caballero S. Boese T. Franklin A.E. Borum J.C. Standards of best practice: Simulation standard VI: The debriefing process.Clinical Simulation in Nursing. 2013; 9: S26-S29Google Scholar, p. S26). The Standard goes on to state that debriefers should have formal training and competence assessment. Competence should be assessed using an established instrument. The National Council of State Boards of Nursing (NCSBN) recently published findings from the landmark National Simulation Study (Hayden et al., 2014Hayden J.K. Smiley R.A. Alexander M. Kardong-Edgren S. Jeffries P.R. The NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education.Journal of Nursing Regulation. 2014; 5: S1-S66Google Scholar). Findings indicated that up to 50% of simulated learning can effectively be substituted for traditional clinical experiences, under conditions similar to those in the study. For further clarification, the NCSBN recently released Simulation Guidelines for Prelicensure Nursing Programs (Alexander et al., 2015Alexander M. Durham C.F. Hooper J.I. Jeffries P.R. Goldman N. Kardong-Edgren S. Tillman C. NCSBN simulation guidelines for prelicensure nursing programs.Journal of Nursing Regulation. 2015; 6: 39-42Google Scholar). In the guidelines, ensuring the competence of debriefing facilitators is addressed in several ways. Since the publication of the National Simulation Study, several state Boards of Nursing have made recommendations about the use of simulation. For example, Florida (http://floridasnursing.gov/latest-news/chapter-2014-92-laws-of-florida-became-effective-on-july-1-2014/) and Maryland now allow up to 50% substitution, without specific guidelines beyond those recommended by the NCSBN. The Arizona State Board of Nursing has published an Advisory Opinion regarding the use of simulation in RN programs. The Advisory Opinion recommends that facilitators have formal immersion training and competency assessment specific to their roles. Congruent with the NCSBN Guidelines, the Arizona Advisory Opinion recommends that programs using simulation in place of traditional clinical experiences adopt the International Nursing Association for Clinical Simulation and Learning (INACSL) Standards of Best Practice: Simulation. The INACSL Standard VI: The Debriefing Process, Criteria 1 states that debriefing should be “Facilitated by a Person(s) Competent in the Process of Debriefing” (Decker et al., 2013Decker S. Fey M. Sideras S. Caballero S. Boese T. Franklin A.E. Borum J.C. Standards of best practice: Simulation standard VI: The debriefing process.Clinical Simulation in Nursing. 2013; 9: S26-S29Google Scholar, p. S26). The Standard goes on to state that debriefers should have formal training and competence assessment. Competence should be assessed using an established instrument. The DASH-Student Version (DASH-SV) was developed to gather student feedback on the debriefing experience, specifically to identify the extent to which students perceive that the facilitator demonstrated the six elements of effective debriefing following simulation sessions. It has been used in several different ways. First, as a quality improvement measure of teaching and learning involving student feedback, an important yet often overlooked component. Using the DASH-SV, students assess the facilitator and how the debriefing impacted their own engagement and learning. Second, the DASH-SV data were used as a part of a 360-degree evaluation process since the DASH-RV and DASH-SV scales use the same six elements and effectiveness scale. Comparing the assessment of students and faculty peers provides insights from the different perspectives and encourages self-reflection. Because the DASH-RV and DASH-SV data can be shared with both groups of raters and the debriefing facilitator, students learn the value of peer evaluations as an important lifelong skill, and faculty learn how students perceive the debriefing experience. Finally, student assessment of debriefing using the DASH-SV can be used as the primary source of feedback when it is not possible to conduct peer review. Inter-rater reliability between the DASH-RV and DASH-SV has been consistently high in some contexts and data from each scale correlate well with each other. The Center for Medical Simulation in Boston provides simulation courses to interprofessional teams, discipline-specific groups, and simulation educators. Center for Medical Simulation faculty must be certified (view process www.harvardmedsim.org). Certification includes an array of experience and professional development requirements, as well as a summative assessment of a recorded debriefing that includes DASH ratings of four or above on all six DASH elements. Our work and continued studies using the DASH have revealed many new pathways for the future of simulation-based learning, including serving as the skeleton for other related assessment tools (e.g., feedback in clinical contexts) and providing the structure for faculty development programs. As the most robust debriefing standard, many researchers and educators are using the DASH to explore many aspects of debriefing toward learning and as an integral part in simulation-based learning. The dimensions, in themselves, serve as research topics for future study.

The anesthetist decided to extubate his patient and first needed to test the patient’s ability to breathe spontaneously. Because of a handling error, the anesthesia machine was not switched into a spontaneous breathing mode, but instead the machine continued to mechanically ventilate the patient. In the mistaken conviction that the patient was breathing on his own, the anesthetist interpreted his clinical observation and the information gathered from his monitor as signs of adequate spontaneous breathing. He saw regular and deep chest excursions, the flawless pattern of the capnography curve and an expiratory minute volume close to what he expected. This evidence reinforced his conviction that the patient could be safely extubated. Other minor problems arose that diverted some of his attention for a short while and he did not realize that his monitor was showing additional ventilation curves that contradicted current assumption (e.g., the pressure/time curve and the flow/time curve). Because he accepted his perception as being in agreement with his working hypotheses of a spontaneously breathing patient, a critical re-examination of the situation did not occur until the patient had serious problems.

A pediatrician is confronted with an emergency in which the leading symptoms can be due to variety of causes. From clinical examination alone she gets no further clues about the etiology of the clinical deterioration. What makes this situation particularly challenging is the fact that some therapeutic actions (e.g., intubation, insertion of a chest tube) might actually worsen the patient’s condition. If her initial diagnosis proves wrong, the wrong intervention may do considerable harm to the young patient.

INTRODUCTION:Despite published recommended best practices for full disclosure and apology to patients and families after adverse medical events, actual practice can be inadequate. The use of "cognitive aids" to help practitioners manage complex critical events has been successful in a variety of fields and healthcare. We wished to extend this concept to disclosure and apology events. The aim of this study was to test if a brief opportunity to review a best practice guideline for disclosure and apology would improve communication performance.METHODS:Thirty pairs of experienced obstetricians and labor nurses participated in a 3-part exercise with mixed-realism simulation. The first part used a standardized actor patient to meet the obstetrical team. The second part used a high-fidelity simulation leading to an adverse medical event (retained sponge), and the third part used standardized actors, patient, and husband, who systematically move through stages of grief response. The participants were randomized into 2 groups, one was provided with a cognitive aid in the form of a best practice guideline for disclosure and apology and the other was only given time to plan. Four blinded raters working in pairs scored subjects on a 7-point scale using a previously developed assessment instrument modified for this study.RESULTS:Pooled ratings of the disclosure and apology discussion for the intervention group (n = 167, mean = 4.9, SD = 0.92) were higher than those from the control group (n = 167, mean = 4.3, SD = 1.21) (P < 0.0001). One specific element was rated higher for the intervention group than the control group; posture toward the patient (n = 27, mean = 5.1, SD = 0.82 versus n = 28, mean = 4.3, SD = 1.33) (P = 0.020). The elements of dealing with anger, dealing with depression, dealing with denial, bargaining, and acceptance were not different.CONCLUSIONS:Experienced practitioners performed better in a simulated disclosure and apology conversation after reviewing a cognitive aid in the form of a best practice guideline than a control group that was only given time to prepare.