Learners will manage an obstetrical complication of a retained placenta.
You are the physician on call for obstetrics this evening at a rural 1A hospital and are woken up by a phone call from the emergency department letting you know a patient arrived in active labour accompanied by her partner, and quickly delivered the baby. According to her partner, the labour started 3 hours prior to their arrival at the hospital, but they live over an hour away, and she progressed rapidly. Fortunately, the physician in the ED was able to assist in the delivery. The healthy baby girl was born 30 minutes ago, and the mother, Amanda, is still in the third stage of labour. A trauma has come into the ED and since the mother is stable and not bleeding, the other physician had run to the trauma. You have been asked to come in and aid in the active third stage of labour.
There are 2 available RNs, however, you have been informed that the patient has a previous relationship with one of them and has asked that they not be part of her care team. Therefore, you and one RN who was present throughout the patient's entire course in the hospital are the staff members available to aid in the rest of Amanda’s labour and delivery.
On examination, the umbilical cord will be presenting from the vagina, with minimal to no bleeding. The learner must obtain a verbal report from the RN and assess the patient to deduce the cause of the retained placenta. The learner will then practice implementing appropriate active management of the third stage of labour in the case of a retained placenta caused by an adherent placenta using manual extraction, with the assistance of one RN.
This simulation is part of ØRECLESS (Rural Emergencies and Complications in Labour Events Simulations Suite).
Overall Goal: Manage an obstetrical complication of a retained placenta caused by an adherent placenta.
Specific Learning Objectives:
Time Recommended: 65 minutes total (10 min Setup | 25 min Scenario | 30 min Debrief)
Patient Recommendation: Standardized Patient + OB Mannequin + OB Trainer
Medical Equipment:
Medications:
Other:
|
This SIM requires one learner. Supporting roles can (1) be assigned to complete tasks by the learner, (2) provide assistance with maneuvers, and (3) provide statements throughout the SIM to allow for progression through the stages.
|
Moulage: Set up with placenta in situ and the umbilical cord clamped and cut presenting from the vagina.
Set-Up: You walk into the patient room where the woman is in a semirecumbent position with her newborn skin-to-skin on her chest, with her support person at the bedside. She has not yet delivered the placenta.
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.
Original Author: Kristen Palumbo
Originally published on: January 2, 2024
Most Recent Modification:
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.
You are the physician on call for obstetrics this evening at a rural 1A hospital and are woken up by a phone call from the emergency department letting you know a patient arrived in active labour accompanied by her partner and quickly delivered the baby. According to her partner, the labour started 3 hours prior to their arrival at the hospital, but they live over an hour away, and she progressed rapidly. Fortunately, the physician in the ED was able to assist in the delivery. The healthy baby girl was born 30 minutes ago, and the mother, Amanda, is still in the third stage of labour. A trauma has come into the ED and since the mother is stable and not bleeding, the other physician had run to the trauma. You have been asked to come in and aid in the active third stage of labour.
There are 2 available RNs, however, you have been informed that the patient has a previous relationship with one of them and has asked that they not be part of her care team. Therefore, you and one RN who was present throughout the patient's entire course in hospital are the staff members available to aid in the rest of Amanda’s labour and delivery.
|
Patient Chart |
||||||||||
|
Name: Amanda Ramsey |
Age: 26 |
Gender: F |
Weight: 76 kg |
Height: 163 cm | ||||||
|
Temp: 36.9 |
HR: 98 bpm |
BP: 119/81 |
RR: 18/min |
O2Sat: 100% |
GCS: 15 |
|||||
| Presenting complaint: Abdominal cramping and vaginal pressure. | ||||||||||
You walk into the delivery room and see your patient, a 26 y/o woman appearing quite tired and lying in a semirecumbent position with her baby skin-to-skin on her chest. The RN is at her bedside, looks a bit unnerved, and tells you the previous physician just left. Gather an appropriate history and assess the woman and fetus.
Verbal Report from RN:
“Amanda came in about an hour and a half ago and was already 10cm dilated! The labour went very quickly, we didn't have time to call you until now. I’ve been here since the beginning. She had a spontaneous vaginal delivery that happened quite quickly without any analgesia. Baby weighed 3033g, Apgars normal. Mom has no tears and barely any bleeding, and we gave her the 10 units of oxytocin IM as she delivered the anterior shoulder, but she hasn’t delivered the placenta yet. There hasn’t been any cord lengthening, gush of blood, change in uterine shape, height, or tone.”
Modifiers (in red): Actions by the learner (which will have a consequence) OR actions to prompt learner. Extra information, audio clips, etc. are provided below.
| Patient Vitals | ||||
| BP: 119/81 | HR (Rhythm): 98 bpm (Normal Sinus) | RR: 18/min. | ||
| O2SAT: 100% | Temperature: 36.9 degrees Celsius | GCS: 15 | ||
| Expected Learner Actions |
|---|
|
Begin Simulation ⇒ Provide verbal report from RN (above). |
| 8 min. OR Actions Complete ⇒ 2. Active Management of Third Stage |
Pronouns: She/he
Obstetrical History: G3T2P0A1L1
Medication(s): None.
Other: No Allergies. Insignificant family history and past medical history.
General Abdominal Exam: No visible asymmetry, lesions, or scars. Fundal height is just below the level of the umbilicus. Uterus is soft and discoid in shape.
You quickly attend to the patient to continue management of the third stage of labour. Inform the mother and her partner of the current situation and discuss the management plan. Gain consent for your intervention.
Modifiers (in red): Actions by the learner (which will have a consequence) OR actions to prompt learner. Extra information, audio clips, etc. are provided below.
| Expected Learner Actions |
|---|
|
Explain the situation to the mother and support person
Gain consent for active management of the third stage of labour |
| 5 min. OR Actions Complete ⇒ 3. Prepare for Manual Extraction of Placenta |
Another 30 minutes have passed. Repeated controlled cord traction has not resulted in cord lengthening or a gush of blood. Uterine characteristics remain consistent. Proceed with informing the patient and preparing for manual extraction.
Modifiers (in red): Actions by the learner (which will have a consequence) OR actions to prompt learner. Extra information, audio clips, etc. are provided below.
| Expected Learner Actions |
|---|
|
Recognize that the placenta has not separated from the uterus (Note: Signs of separation include lengthening of the umbilical cord, gush of blood from the vagina, change in the shape of the uterine fundus from discoid to globular, elevation of the fundal height, and contraction of the fundus) |
| 5 min. OR Actions Complete ⇒ 4. Manual Extraction of Placenta |
Uterotonics and controlled cord traction have been unsuccessful in managing the delivery of the placenta. Manage the third stage of labour by manually extracting the placenta.
Modifiers (in red): Actions by the learner (which will have a consequence) OR actions to prompt learner. Extra information, audio clips, etc. are provided below.
| Expected Learner Actions |
|---|
|
Manual extraction of placenta Additional Information (Difficult or Incomplete Extraction)
*Placenta accreta is rarely first found at the time of delivery. In these rare cases, placenta accreta is diagnosed when there is no plane of dissection and/or areas of myometrial invasion prevent clean separation of part of the placenta during an attempt at manual removal. In such a case, an attempt at separation is likely to cause severe hemorrhage. If there is any evidence or significant suspicion that one is dealing with a placenta accreta, transfer immediately to the nearest tertiary centre able to manage this effectively. |
| 7 min. OR Actions Complete ⇒ 5. Case Complete |
The placenta has been successfully delivered. An initial gush of blood followed manual extraction of the placenta, but the bleeding has significantly slowed since. The drape was removed from under the mother, weighing 400g heavier than its dry weight (~400mL blood lost). The uterus is firm on palpation and is approximately a handbreadth beneath the umbilicus. Amanda’s vitals are stable and bleeding is minimal, but will continue to be monitored every 15 minutes for at least an hour. Her partner is at the bedside along with their healthy newborn. The case is complete.
|
Date and Time |
|
|---|---|
|
ID
|
CC
|
|
HPI: 4 Key Questions
|
Hx of Pregnancy
|
|
OBHx: Outcomes of previous pregnancies
|
|
|
PMHx
|
|
|
On Examination (O/E)
|
|
|
GxPx |
GTPAL |
|
G = Gravidity → total # of pregnancies |
G = Gravidity → total # of pregnancies
L = number of living children |
E.g., Patient has been pregnant 4 times. The first one ended in a miscarriage at 10 weeks, the second child was born healthy at 38 weeks, the third was carried to 23 weeks but was born stillborn and she is currently 35 weeks gestation with the fourth pregnancy.
This can be described as: G4P2 in GxPx format or G4T1P1A1L1 in the GTPAL format.
|
First Stage |
|
|
Latent Phase Duration: Nulliparous: <20h Multiparous: <14h Clinical Features: Contractions:
Changes in Dilation:
|
Active Phase Duration: Nulliparous: 4-6h Multiparous: 2-3h Clinical Features: Contractions:
Changes in Dilation:
|
|
Clinical Features (Latent & Active Phases):
Overview of Physician Role:
|
|
|
Second Stage |
|
|
Duration: Nulliparous: <2h (3 with epidural) Multiparous: <1h (2 w/ epidural) Clinical Features:
Overview of Physician Role:
|
|
|
Third Stage |
|
|
Duration: 30 minutes Clinical Features:
Overview of Physician Role:
|
|
|
Fourth Stage |
|
|
1-2 hour postpartum period Clinical Features:
Overview of Physician Role:
|
|
Important Notes Regarding Pharmacological use in Labour:
Options for Pharmacological Pain Management in Labour (see dosing information below):
Suggested Opioid use in labour:
|
Stage of Labour |
Nulliparous |
Parous |
|
Latent Stage: |
IM/SC Morphine |
IM/SC Morphine |
|
Early Active Stage: |
IM/SC or IV Morphine |
IV Morphine or Fentanyl |
|
Late Active Stage: |
IV Morphine or Fentanyl |
IV Fentanyl |
|
Second Stage: |
IV Fentanyl |
IV Fentanyl |
Reference(s):
Grant G. (2022). Pharmacologic management of pain during labor and delivery. In Crowley M (Ed.), UpToDate. Retrieved Jul 2, 2023, from https://www.uptodate.com/contents/pharmacologic-management-of-pain-during-labor-and-delivery
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.
Brandt-Andrews Maneuver (preferred): an abdominal hand secures the uterine fundus to hold it in a fixed position and prevent uterine inversion while the other hand exerts sustained downward traction on the clamped umbilical cord.
Reference(s):
Anderson, Janice M, and Duncan Etches. 2007. Prevention and Management of Postpartum Hemorrhage. www.aafp.org/afp. (October 12, 2023).
|
Definition |
|
Lack of placental expulsion within 30 minutes of delivery. This time period can be extended to 90 to 120 minutes in the absence of hemorrhage for births in the second trimester and third stages of labor managed without oxytocin. In 80% of term births, the placenta is expelled within 30 minutes and in 98% within 1 hour. |
|
Etiology & Clinical Features |
|
There are 3 types of retained placenta:
|
|
Risk Factors |
|
|
Complications |
|
Most common complications include postpartum hemorrhage and postpartum endometritis. Uterine inversion is less common. Fatality is quite rare in high-resource settings. |
|
Management |
|
Indications for Intervention:
Management:
|
|
Reference(s) Erickson, A. & Parker, J. (Eds.). (2023). Toronto Notes 2023: Comprehensive Medical Reference and a Review for MCCQE. Toronto Notes for Medical Students Inc. Weeks, A. (2023). Retained placenta after vaginal birth. In Barss V (Ed.), UpToDate. Retrieved August 9, 2023 from https://www.uptodate.com/contents/retained-placenta-after-vaginal-birth?search=retained%20placenta%20after%20vaginal%20birth&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 |
IV: intravenous
IM: intramuscular
TXA: tranexamic acid
CCT: controlled cord traction
group and save: this is another term for type and screen or type and hold.
*Generic name ergometrine-oxytocin.
Reference(s):
Weeks, A. (2023). Retained placenta after vaginal birth. In Barss V (Ed.), UpToDate. Retrieved August 9, 2023 from https://www.uptodate.com/contents/retained-placenta-after-vaginal-birth?search=retained%20placenta%20after%20vaginal%20birth&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
| Signs of Placental Separation | |
|
1. Gush of blood |
|
| Active Management | |
|
|
Drug Name |
Characteristics |
Side Effects |
PPH Usage |
|
|
Medication Class: Oxytocics |
||||
|
Oxytocin |
Preferred first line uterotonic Stimulates muscle of upper uterine segment causing contraction to compress blood vessels IV: acts immediately IM: 3-5 minutes |
Rare: nausea, vomiting, headache, flushing Never give as IV bolus → hypotension, tachycardia & potential cardiovascular collapse possible Water intoxication with high doses, prolonged infusion, or hypotonic IV solution → Use normal saline or Ringers Lactate |
Prevention Vaginal Delivery:
Cesarean (elective):
Cesarean (intrapartum):
Treatment: 20-40 IU in 1000 mL normal saline, initially wide open |
|
|
Carbetocin |
Long-acting oxytocin analogue Alternative agent if oxytocin is not available or consider if pt. is at high risk of PPH |
Nausea, vomiting, flushing, headache |
Prevention Vaginal Delivery: 100 mcg IM Cesarean: 100 mcg over ≥ 30 seconds Treatment: Limited data available |
|
|
Medication Class: Ergot Alkaloids |
||||
|
Ergot Alkaloids |
Stimulates myometrium of upper AND lower uterine segments IM: 2-5 minutes IV: acts <1 minute (however, IV not recommended) |
Nausea, vomiting, hypertension Contraindicated in all hypertensive disorders of pregnancy |
Prevention: 0.2-0.25 mg IM Treatment: 0.2-0.25 mg IM (may repeat at 2h intervals) |
|
|
Medication Class: Prostaglandins |
||||
|
Misoprostol |
Prostaglandin E1 Causes vasoconstriction & enhanced contractility of the myometrium |
Fever (most common with >600 mcg) |
Prevention: 400 mcg SL (SL achieves highest serum peak level) Treatment |
|
|
Carboprost |
Prostaglandin F2α Causes vasoconstriction & enhanced contractility of myometrium |
Vomiting, diarrhea, fever, bronchospasm Use with extreme caution if asthma or major cardiovascular, renal, or hepatic dysfunction) |
Treatment |
|
|
Medication Class: Tranexamic Acid |
||||
|
Tranexamic Acid |
Not a uterotonic Inhibits fibrinolysis Consider in pt. at very high risk of PPH |
N/A |
Prevention Vaginal Delivery: 1 g IV over 10 minutes within 10 minutes after vaginal delivery Cesarean: 1 g IV over 10 minutes before skin incision Treatment |
|
Reference(s):
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.
Equipment Recommendations:
Monitoring:
Antiemetics
Dosing
Procedural Sedation & Analgesia Medications & Dosing
Adapted from Frank, R. L. (2023). Procedural sedation in adults: Medication selection, dosing, and discharge criteria. M Ganetsky (Ed.) UpToDate. Retreived August 23, 2023 from https://www.uptodate.com/contents/procedural-sedation-in-adults-medication-selection-dosing-and-discharge-criteria?search=procedural%20sedation%20drugs&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H3175829286
Provincial Massive Hemorrhage Protocol: https://transfusionontario.org/wp-content/uploads/2021/10/Recommendation-Statements_April-2021-1.pdf
Ontario Regional Blood Coordinating Network. Ontario MHP: Guidance for small/remote hospitals. https://youtu.be/ofvNsScQ58M?feature=shared
Refractory Hemorrhage Caution:
E.g., for hemorrhagic shock with ongoing bleeding, crystalloid administration may dilute the coagulation factors and RBC concentration. Beginning resuscitation with crystalloid early may promote volume overload.
Minimum Laboratory Protocol Resuscitation Targets for Transfusion:
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.
|
|
|||||
|
Time |
Facilitator Level |
Prep Time |
Scenario Type |
Flexibility |
|
|
Moderate |
Novice |
Moderate |
Any |
High |
|
|
Short-Moderate |
Novice |
Low |
Short w/ Clear Objectives |
Low |
|
|
Moderate |
Novice |
Moderate |
Any, esp. Team-focused |
Moderate |
|
|
Very Short |
No experience |
None |
Any |
Low |
|
|
Short |
Novice |
Low |
Low number of non-technical skills |
Low |
|
|
Very Short |
No experience |
None |
Any |
Moderate |
|
|
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
|
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”
|
||
|
2. Reactions |
Explore feelings |
Solicit initial reactions and emotions
|
“Any initial reactions?” “How are you feeling?” |
||
|
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?”
|
||
|
4. Analysis |
Explore a variety of performance domains:
|
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?" |
||
|
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]”
|
||
|
Analysis Phase Details |
|||||
|
Choose an analysis approach (Different approaches can be used for different topics within the same analysis stage): |
|||||
|
Approach |
Objective |
Sample Phrases |
|||
|
Learner Self-Assessment
|
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?”
|
|||
|
Focused Facilitation
|
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?” |
|||
|
Provide Information
|
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]” |
|||
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
|
Phase |
Goal |
Actions |
Possible Scripts |
|
Gather (Listen)
25% |
|
|
How do you feel? |
|
How do you think it went? Can you tell me what happened? |
||
|
Can anyone add anything to that account? |
||
|
Analyze (Guide Reflection)
50% |
|
|
I noticed… |
|
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? |
||
|
Tell me more about… How did you feel about…. I understand, but tell me about X aspect of the scenario |
||
|
Summarize (Help gather Conclusions)
25%
|
|
|
What are two things that you thought were effective or went well? |
|
What do you think are some areas you/your team need to work on? |
||
|
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” |
|
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…” |
|
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.
|
|
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….? |
||
|
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 |
||
|
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:
Second and Third Stage of Labour:
