68 y/o is brought to the ED expressing paranoid delusions and exhibiting bizarre behaviour. Her agitation escalates and she will require physical and chemical sedation to facilitate management.
A 68-year old woman is found at a bus stop exhibiting bizarre behaviour. She is brought to the ED by paramedics. In the ED, she is expressing paranoid delusions. Her agitation escalates and does not respond to verbal de-escalation or an overwhelming show of force. She will require physical and chemical sedation to facilitate the work-up for her new onset psychosis.
Disclaimer: This case may involve physical restraint. Both the standardized patient and sim participants should be briefed on the use of simulated restraint. It is essential that a safe word like “Time out” is pre-determined in case any participants are feeling unsafe at any point in the case. This would immediately halt the case. A detailed pre-briefing regarding safety and an extremely clear explanation of this safe word are paramount. Similarly, instructors must be watching closely for safety and cut the scenario/intervene quickly if they feel anyone may be harmed.
Overall Goal: To allow learners to become more comfortable managing severe agitation requiring chemical sedation
Specific Learning Objectives:
Time Recommended: 40 minutes total (10 min Setup | 10 min Scenario | 20 min Debrief)
Patient Recommendation: Standardized patient + Intubatable Manikin
Medical Equipment:
Medications:
Essential
| Role | Description (Role, Behaviour, Key Moments, Script) |
| Patient |
Talking incessantly about your neighbour putting poison in your coffee and cameras in your apartment. You state that he records your every move. If anyone tries to obtain You look around room at nothing in particular due to visual hallucinations.
Once given chemical sedation, you will calm down |
Optional
| Role | Description (Role, Behaviour, Key Moments, Script) |
| RN |
Act as a typical ED Nurse. Assist with bedside care. Mock up the administration of IM sedation in order to ensure that the patient is not harmed or given any actual injections. Stage 1
|
| Security | Act as hospital security/police. Assist with physical restraint. |
Moulage: Person playing patient should look unkempt and disheveled.
Set-Up: Minimal physical set-up needed. Patient should be pacing in ER room. Ensure that physical restraints are available and that learners know how to use them.
Note: While prepping for your simulation, don't forget to prep for the debrief. Become comfortable with your chosen framework, review your objectives. For additional debriefing resources, see our Resources page.
Credits:
Original Author: Dr Nicole Keester-Greene, Dr Jen Riley
Date: 2015
Originally published on: EM Sim Cases
Most Recent Modification: July 2021
Modified by: Mateo Orrantia
A good prebriefing is an essential component of running effective simulations, as it sets the stage for everything that comes after it1-3. An effective prebrief will create a safe container for learning, and in doing so, help participants feel more comfortable pushing their limits, sharing their thoughts and feelings, and buying into the experience. In turn, this will enhance engagement, participation, and learning. To that end, the prebriefing process needs to cover a lot of information1-5, which can make it daunting to novice or non-expert facilitators. To help, we have consulted the relevant literature and put together a prebrief guide to ensure that you have the tools you need to run an effective pre-briefing session.
Throughout the pre-brief, it is important that you convey your commitment to respecting learners and their perspective2-4, and establish and maintain the simulation as a safe space for learning1,4,5.
Prebrief Guide (Sample Phrases in Italics)
Welcome learners. Introduce yourself, your role, and your experience with simulation.
Go over the time requirements for the simulation, when breaks will occur, how learners should handle incoming calls or texts, etc.
Clarify the learning objectives for the simulation1-5. Give information on the purpose of the simulation without giving out specific actions or information that might compromise the learning experience for participants.
Explain how participants will be evaluated (formative/summative/not evaluated). Briefly discuss the debrief process that will take place at the end of the simulation.
Give details on what expectations are for the learners' behaviour during the simulation, setting basic ground rules2-5. Go over expectations for yourself as the facilitator. Reinforce the simulation as a learning environment, where mistakes aren't something to be punished but opportunities for further learning.
This could be a good place to pause and ask learners if they have any additional expectations, fears, comments, or questions about the topic for the day.
Ensure all participants agree to the confidentiality expectations of the simulation. Often, this will follow the mantra of "What happens in the simulation stays in the simulation," where learners and instructors agree not to share information on others' performance or scenario details outside of the simulation environment.
Explain that you've done what you can to make the simulation as real as possible, but acknowledge the limitations. Ask the learner to commit to doing what they can to act as if everything was real, explaining that the quality of their learning will depend on their willingness to participate as fully as possible. For the first simulation with a new group, it could be helpful to explain the importance of a mutual fiction contract.
Explain the different roles in the simulation and assign learners to them. If you have predetermined scripts for certain roles, hand them out here.
Explain the resources that will be available for the participants to use, how they should call for help in the simulation, what your role will be in providing information.
Orient participants to simulation space, equipment, manikin, etc. This can also be done by allowing participants to explore the simulation space and manikin for themselves.
Ask for questions!
References
1. Rudolph JW, Raemer DB, Simon R. Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simul Healthc. 2014 Dec;9(6):339-49. doi: 10.1097/SIH.0000000000000047. PMID: 25188485.
2. Leigh G, Steuben F. Setting Learners up for Success: Presimulation and Prebriefing Strategies. Teaching and Learning in Nursing. 2018; 13(3):185-189. https://doi.org/10.1016/j.teln.2018.03.004
3. Lecomte F, Jaffrelot M. Chapter 33 - Prebriefing and Briefing. Clinical Simulation. 2019; 2nd ed.; 471-482. https://doi.org/10.1016/B978-0-12-815657-5.00034-6.
4. INACSL Standards Committee (2016, December). INACSL standards of best practice: SimulationSM Facilitation. Clinical Simulation in Nursing, 12(S), S16-S20. http://dx.doi.org/10.1016/j.ecns.2016.09.007.
5. Simon R, Raemer D, Rudolph J. Rater's handbook for the Debriefing Assessment for Simulation in Healthcare (DASH) Rater Version. 2009. http://www.harvardmedsim.org/debriefing-assesment-simulation-healthcare.php.
The charge nurse comes to you: “There is a 68 year old woman in the seclusion room. She was observed pacing and acting bizarre at the bus stop. EMS managed to talk her into ambulance. On route she told them her neighbour is trying to poison her. Initially, she was calm but now she is starting to get agitated. She doesn’t have any previous psych admissions in the system. We couldn’t get any vital signs.”
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Patient Chart |
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Patient Name: Amina Patel |
Age: 68 |
Gender: F |
Weight: 70kg |
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Presenting complaint: Bizarre Behaviour |
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Temp: |
HR: |
BP: |
RR: |
O2Sat: |
FiO2: |
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Cap glucose: |
GCS: |
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Triage Note: Seen at bus stop acting strangely. Bystander called EMS. |
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Allergies: Unknown |
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Past Medical History: Hypertension |
Current Medications: Hydrochlorothiazide |
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Further History: No history available. Unable to reach emergency contacts.
| Physical Exam | |
| Cardio: Unable to assess | Neuro: Responding to visual hallucinations. No obvious neurological deficits. |
| Resp: Unable to assess | Head & Neck: Unable to assess |
| Abdo: Unable to assess | MSK/Skin: Unable to assess |
| Other: Agitated and paranoid | |
The charge nurse comes to you: “There is a 68 year old woman in the seclusion room. She was observed pacing and acting bizarre at the bus stop. EMS managed to talk her into ambulance. On route she told them her neighbour is trying to poison her. Initially, she was calm but now she is starting to get agitated. She doesn’t have any previous psych admissions in the system. We couldn’t get any vital signs.”
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Patient Chart |
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Patient Name: Amina Patel |
Age: 68 |
Gender: F |
Weight: 70kg |
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Presenting complaint: Bizarre Behaviour |
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|
Temp: |
HR: |
BP: |
RR: |
O2Sat: |
FiO2: |
||||
|
Cap glucose: |
GCS: |
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Triage Note: Seen at bus stop acting strangely. Bystander called EMS. |
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Allergies: Unknown |
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Past Medical History: Hypertension |
Current Medications: Hydrochlorothiazide |
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The patient is agitated and paranoid, pacing the room. Will not allow RN assessment or monitors.
| Patient State/Vitals - Unable to Obtain | ||||||
| Rhythm: | HR: | BP: | RR: | |||
| O2SAT: | T: | GCS: | ||||
| Expected Learner Actions | Modifiers | Triggers |
|---|---|---|
|
Attempt verbal de-escalation |
5 Minutes ⇒ RN suggest "Should we If no sedation 2 min after prompt ⇒ RN suggest "This is dangerous agitation |
Appropriate Dose Sedation ⇒ 2. Sedated Large Dose Sedation ⇒ 3. Over-Sedated |
The patient is agitated and paranoid, pacing the room. Will not allow RN assessment or monitors.
| Patient State/Vitals - Unable to Obtain | ||||||
| Rhythm: | HR: | BP: | RR: | |||
| O2SAT: | T: | GCS: | ||||
Exchange the patient actor for an intubatable Manikin.
Patient drowsy.
| Patient State/Vitals | ||||||
| Rhythm: Sinus tach | HR: 105 | BP: 110/70 | RR: 12 | |||
| O2SAT: 90% | T: 36.3oC | GCS: 12 (E3M5V4) | ||||
| Expected Learner Actions | Modifiers | Triggers |
|---|---|---|
|
IV access, Monitors, O2 |
IV fluids ⇒ HR 90 O2 given ⇒ O2SAT 96% |
All actions complete ⇒ 5. Resolution |
This ECG shows a Sinus rhythm with normal QTc.
Tox and Sepsis will be negative, and CBG will be normal.
| Patient State/Vitals | ||||||
| Rhythm: Sinus tach | HR: 105 | BP: 110/70 | RR: 12 | |||
| O2SAT: 90% | T: 36.3oC | GCS: 11 (E3M5V4) | ||||
Exchange patient actor for intubatable manikin.
Patient non-responsive, but has a pulse.
| Patient State/Vitals | ||||||
| Rhythm: Sinus | HR: 90 (↓) | BP: 95/55 (↓) | RR: 6 (↓) | |||
| O2SAT: 80% (↓) | T: 36.3 | GCS: 3 (↓) | ||||
| Expected Learner Actions | Modifiers | Triggers |
|---|---|---|
|
IV access, Monitors, O2 |
O2 ⇒ O2SAT 85% |
Intubation ⇒ 4. Intubated |
| Patient State/Vitals | ||||||
| Rhythm: Sinus | HR: 90 (↓) | BP: 95/55 (↓) | RR: 6 (↓) | |||
| O2SAT: 80% (↓) | T: 36.3 | GCS: 3 (↓) | ||||
Patient intubated and sedated.
| Patient State/Vitals | ||||||
| Rhythm: Sinus | HR: 80 (↓) | BP: 105/65 (↑) | RR: 12 (↑) | |||
| O2SAT: 99% (↑) | T: 36.3 | GCS: 2T | ||||
| Expected Learner Actions | Modifiers | Triggers |
|---|---|---|
|
Physical Exam (will find nothing remarkable) |
No modifiers for this stage |
All actions ⇒ 5. Resolution |
This ECG shows a normal sinus rhythm.
BW will be negative for Tox and Sepsis, and other wise normal.
This x-ray shows a successful intubation and normal chest.
| Patient State/Vitals | ||||||
| Rhythm: Sinus | HR: 80 (↓) | BP: 105/65 (↑) | RR: 12 (↑) | |||
| O2SAT: 99% (↑) | T: 36.3 | GCS: 2T | ||||
| Patient State/Vitals | ||||||
| Rhythm: Sinus | HR: 90 | BP: 105/65 | RR: 12 | |||
| O2SAT: 98% | T: 36.3 | GCS: 11 (2T if intubated) | ||||
| Expected Learner Actions | Modifiers | Triggers |
|---|---|---|
|
Foley, UA |
No Modifiers for this Stage |
Consultation Complete ⇒ Debrief |
| Patient State/Vitals | ||||||
| Rhythm: Sinus | HR: 90 (↑) | BP: 105/65 | RR: 12 | |||
| O2SAT: 99% | T: 36.3 | GCS: 2T | ||||
| Patient State/Vitals | ||||||
| Rhythm: Sinus | HR: 90 (↓) | BP: 105/65 (↓) | RR: 12 | |||
| O2SAT: 96% (↓) | T: 36.3 | GCS: 11 | ||||
Choosing a Debrief Framework:
A good debrief has been identified in the literature as the most important part of a successful simulation experience. If you're a novice or inexperienced facilitator, use this table to help you choose which debrief framework you want to use, just tap the button on their name and you will be directed to the appropriate aids or scripts. While we recommend the PEARLS framework, take a look to see if there may be another that is a better fit for your situation.
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Time |
Facilitator Level |
Prep Time |
Scenario Type |
Flexibility |
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Moderate |
Novice |
Moderate |
Any |
High |
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Short-Moderate |
Novice |
Low |
Short w/ Clear Objectives |
Low |
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Moderate |
Novice |
Moderate |
Any, esp. Team-focused |
Moderate |
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Very Short |
No experience |
None |
Any |
Low |
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Short |
Novice |
Low |
Low number of non-technical skills |
Low |
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Very Short |
No experience |
None |
Any |
Moderate |
|
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Moderate-Long |
Novice |
Moderate |
Any |
Moderate |
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
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Phase |
Objective |
Task |
Sample Phrases |
||
|
1. Setting the Scene |
Create a safe context for learning |
State the goal of debriefing; articulate the basic assumption |
“Let’s spend X minutes debriefing. Our goal is to improve how we work together and care for our patients.” “Everyone here is intelligent and wants to improve”
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2. Reactions |
Explore feelings |
Solicit initial reactions and emotions
|
“Any initial reactions?” “How are you feeling?” |
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3. Description |
Clarify Facts |
Develop a shared understanding of the case |
“Can you please share a short summary of the case?” “What was the working diagnosis? Does everyone agree?”
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4. Analysis |
Explore a variety of performance domains:
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See bottom of guide for details on the analysis phase |
For each item to be debriefed: 1. Preview Statement: (to introduce topic)
2. Pick Analysis method + Analyze: (see below for more info on each method)
3. Mini Summary: (to summarize discussion of topic)
Phase Wrap-up: "Any outstanding issues or concerns before we start to close?" |
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5. Application or Summary |
Identify take-aways |
Can be learner- or instructor-centered |
Learner-centered: “What are some takeaways from this discussion for our clinical practice?”
Instructor-centered: “The key learning points for the case were [insert learning points]”
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Analysis Phase Details |
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Choose an analysis approach (Different approaches can be used for different topics within the same analysis stage): |
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Approach |
Objective |
Sample Phrases |
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Learner Self-Assessment
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Promote reflection by asking learners to assess their own performance |
“What aspects were managed well and why?”
“What aspects do you want to change and why?”
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Focused Facilitation
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Probe deeper on key aspects of performance, uncover mental frames guiding performance |
Use Advocacy-Inquiry Method Advocacy: "I saw [observation], I think [your point-of-view]” "I noticed [observation] I liked that/I was concerned..." Inquiry: “How do you see it? What were your thoughts at the time?” |
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Provide Information
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Teach to close clear knowledge gaps as they emerge and provide directive feedback as needed |
“I noticed[behaviour]. Next time you may want to consider [suggested behaviour], because [rationale]” |
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PDF from debrief2learn.org: Here
Visual Guide: debrief2learn.org
Alternative Script: Here
Originally Created by: Bajaj K, Meguerdichian M, Thoma B, Huang S, Eppich W, Cheng A. The PEARLS Healthcare Debriefing Tool. Acad Med. 2018, 93(2), 336.
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
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Phase |
Goal |
Actions |
Possible Scripts |
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Gather (Listen)
25% |
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How do you feel? |
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How do you think it went? Can you tell me what happened? |
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Can anyone add anything to that account? |
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Analyze (Guide Reflection)
50% |
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I noticed… |
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I noticed…. What was the thought process behind…. When….happened, I saw….What do you think….. I saw…I think….How do you see it? |
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Tell me more about… How did you feel about…. I understand, but tell me about X aspect of the scenario |
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Summarize (Help gather Conclusions)
25%
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What are two things that you thought were effective or went well? |
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What do you think are some areas you/your team need to work on? |
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In today’s session, we…. Going forward, we should…. |
References/Adapted From:
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
Instructions:
|
Actions |
Gather |
Analyze |
Summarize |
|
Closed-loop communication
Clear Messages
Clear Roles
Knowing one’s limitations
Knowledge Sharing
Constructive Intervention
Reevaluation and Summarizing
Mutual Respect
|
Student Observations
Instructor Observations
|
Done Well
Needs Improvement
|
Student-led Summary
Instructor-led Summary
|
References/Adapted from:
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
|
|
Set learning objectives |
|
After Case |
How did it go? Address Concerns Review learning points Plan ahead |
Framework from:
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
|
Diamond Debrief: Sample Phrases |
|
Description |
|
“So what happened?...and then what happened next?”
Continue asking until confident that the details of the scenario have been raised by the learners
“Let’s not judge our performance now, let’s just focus on what happened” |
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Transition |
|
“This scenario was designed to show…”
“Let’s address technical and clinical questions. What is the protocol for…?”
“How do we normally deal with this clinical situation?”
“Everyone ok with that?” |
|
Analysis |
|
“How did that make you feel?” To participants, then group “Why?” Then use silence
“How did you/they do that exactly?” “Why did you respond in that way? “ or “Why did you take that action?”
“It feels like…was an issue. Did it feel like that to you?” What I’m hearing from you is…is that correct?”
“This is part of…” (identify the non-technical skill/human factor) “We refer to that as a human factor or non-technical skill, which means…” |
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Transition |
|
“So, what we’ve talked about in this scenario is…” “What have we agreed we could do?” |
|
Application |
|
“What other kinds of situations might you face that might be similar? How are they similar?”
“How might these skills we discussed play out in those situations?”
“What are you going to do differently in your practice going forward?” |
|
Underlying Principles |
|
Description |
|
Reinforce a safe learning environment. Situate the debrief in the shared and meaningful activity that occurred. Keep the focus dispassionate—discuss what happened but avoid focus on emotions. Listen for emotional responses but resist the temptation to discuss emotions. Make sure everyone shares the same understanding of what happened.
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Transition |
|
Transition into analysis by clarifying any technical and clinical issues |
|
Analysis |
|
Spend most of your time in Analysis. Deconstruct behaviours into specific actions, and explore what happened in detail. Ask about affective responses and validate them. Analyze and interpret the activity by applying appropriate frameworks or lenses (such as non-technical skills, or the clinical context surrounding the scenario). Keep discussion positive, and avoid the temptation to focus on “strengths and weaknesses”. Reflect responses back, allowing participants to amend or augment. |
|
Transition |
|
Transition into Application by reinforcing learning. |
|
Application |
|
Focus on moving from the specifics of the scenario to the more general world of practice. Break behaviours down into specific actions. Explore the other kinds of situations that these might apply to. Ask what participants will do differently in their practice. |
Adapted From: Jaye P, Thomas L, Reedy G (2015). 'The Diamond': a structure for simulation debrief. The Clinical Teacher 12(1). 171-175. onlinelibrary.wiley.com/doi/full/10.1111/tct.12300
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
Pluses:
Deltas:
|
Plus (+) |
Delta (∆) |
References:
((To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
|
Phase |
Purpose |
Process |
Sample Phrases |
|
Reactions |
|
|
How are you feeling? What are some initial reactions to what just happened? So, in that scenario… |
|
Analysis |
|
1. Observe an event or result. Comment on the observation.
2. Advocate for your position |
I saw that… I think… I noticed that…To me…
I saw…I’m concerned that… |
|
3. Investigate basis for learner’s thinking that led to the observed event or result |
What do you think? Why do you think that happened? How do you see it? What was the thought process behind….? |
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4. Close the gap through discussion and didactics |
I hear…. What would it take for you to do this next time? How could we do this differently next time? I think a few good ideas that came up were… I’d like to say a little bit about…from my experience/literature |
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|
Summary |
|
|
What are some takeaways from today? What went well today? What would you do differently next time?
In today’s session, we…. Going forward, we should… |
Adapted from:
1. It is very important that you become familiar with security/safety protocols at your facility. Often, it can be a good idea to call police/security as early as possible.
2. Restraints should be used sparingly and with utmost caution, as they can sometimes cause harm to patients. Make sure that you are familiar with how to use the restraints at your facility so that they can be applied as safely as possible.
