Scenario is meant to expose learners to caring for refugee patients in a resource-limited setting. They will get to interview an individual who is currently living in a refugee camp presenting with new onset fever, diarrhea, and weakness
The purpose of this scenario is to allow students the opportunity to obtain the social history of a patient of a vulnerable population without judgement or discrimination. As the scenario progresses, the student will work to understand the etiology of the patient’s symptoms, taking into consideration the unique contextual factors involved in living in a refugee camp that may be contributing to the patient’s symptoms. Students are encouraged throughout the scenario to choose their assessments and resources wisely, given the limited access to laboratory and
diagnostic services at the mobile clinic.
This should occur alongside the students addressing psychosocial components overlaying the patient’s symptoms today. The students should attempt to determine whether there have been any effects on the patient’s mental health and wellbeing from the recent displacement, and will learn that their patient has been experiencing early signs of PTSD related to trauma witnessed before coming to the camp.
Overall Goal: Manage a refugee patient in a resource-limited setting
Specific Learning Objectives:
Time Recommended: 30-45 minutes total (X min Setup | 15-30min Scenario | 15min Debrief)
Patient Recommendation: Standardized patient
Medical Equipment: None needed
| Role | Description (Role, Behaviour, Key Moments, Script) |
|
Patient (SP) |
Interviewed by medical student team. Appears somnolent and weak but alert enough to answer questions. |
| Nurse (Facilitator) | Responsibility: support learners in providing lab and imaging results as requested. Intervene if indicated (see below). Statement at the start of scenario: “I am here to support if you need something ordered or need to find a resource/guideline, but the clinic is very busy so I can’t help with everything” |
Moulage: None necessary
Set-Up: None necessary, outside of briefing SPs
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: Katie Zugic
Date: Oct 11 2022
Originally published on:
Most Recent Modification: Oct 11 2022
Modified by: Ashlyn Kopanski, Jenna Simpson and Lobna Abdel-Dayem (VP EDI Sr and Jr), Jane Keating, Tiana Bressan, Erica Dzuba, Kelly Merla, Dr. Anawati
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 volunteering with Medecins Sans Frontieres working in the mobile clinic in the Zaatari refugee camp in Jordan with Dr. Krause when a young woman is brought in by a concerned looking male. Her arm is slung around his shoulder for support and she appears lethargic and diaphoretic. At the same time a small child is brought in in acute distress. Dr. Krause points at the young woman and tells you to see her while he attends to the child.
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Patient Chart |
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Patient Name: Mali Reynaud |
Age: 27 |
Gender: F |
Weight: 55kg |
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Presenting complaint: New onset fever, diarrhea, weakness |
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Temp: 38.9C |
HR: 110 |
BP: 87/65 |
RR: 18 |
O2Sat: 99% |
FiO2: RA |
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Cap glucose: 5.6mmol/L |
GCS: 15 |
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Triage Note: 3 day history of fever, diarrhea, weakness |
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Allergies: NKDA |
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Past Medical History: Broken radius (8yrs old) |
Current Medications: None |
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| Physical Exam | |
| Cardio: Faint pulse, tachycardic, heart sounds normal | Neuro: decreased strength U and L extrem. Fatigues easily |
| Resp. Normal | Head & Neck: Normal |
| Abdo: Pain LLQ and RUQ, Guarding on palpation Tender diffusely Hepatomegaly |
MSK/Skin: Slightly jaundiced |
| Other: | |
HPI: Mali is living in the Zaatari refugee camp in Jordan, after being forcibly displaced from her home in Syria (or other country depending on SP). The camp is overcrowded, Mali is living in a small shelter with her partner Kash and two other families they do not know. Mali has been living in the camp for about one month, and has not had access to any medical attention until today. For the last three days she has been experiencing worsening abdominal cramping, nausea, and more frequent bowel movements. Her stool is loose and watery, though it is hard to tell if there is blood since they are sharing a pit latrine that is quite dark. It is warm in the camp, but she feels warmer than usual, and thinks she is running a fever. She has not eaten much in the last few days since her appetite is diminished. She has been nauseous and is vomiting as well. Today she woke up feeling weak, disoriented, and dizzy. Her partner Kash brought her to the mobile MSF clinic that you are volunteering in.
On exam, Mali’s abdomen is sore, and is tender to the touch, especially in the left lower quadrant and right upper quadrant. She has experienced some cramping, colicky pain diffusely across the abdomen, as well as some increased flatulence. It is worst in the right upper quadrant (“under my ribs on the right side”) and in the left lower quadrant. She has been nauseous for the last few days and there has been some vomiting. She has heard that others in the camp are feeling sick too, but hasn’t had the energy to find out more information about this.
Psychiatric: She is experiencing substantial stress from her recent move, as her family was sent to the Azraq refugee camp, located in Eastern Jordan. She has been having new, vivid nightmares for the last few weeks affecting her ability to sleep. These dreams are littered with images of the violence she witnessed while in Syria (or other country depending on SP). She has noticed that her mood has become lower and that she was becoming increasingly restless and anxious before the fatigue and this illness hit.
Context
1) Infrastructure and hygiene in the camp: Their drinking water comes from a well, bathroom access is a shared latrine, and access to cooking appliances to prepare and heat food is inconsistent.
2) Sick contacts: She has heard that others in the camp are ill, but she hasn’t had the energy to learn more about this
a) If students ask the Nurse: “Yes, there seems to be something going around, but we aren’t sure what.”
Screening: Hasn't seen doctor since she was a young child. No pap tests or other screening measures completed that she can remember
Vax Status: Can't remember which vaccines, if any, she's ever had
Social
Family - Family transferred to Azraq refugee camp in Eastern Jordan. Mali placed here with partner
Current Housing - Shared shelter with 2 families in Zaatari camp, Jordan
Patient somnolent and weak
| Patient State/Vitals - Not initially provided to learners | ||||||
| Rhythm: | HR: 110 | BP: 87/65 | RR: 18 | |||
| O2SAT: 99% | T: 38.9 | GCS: 15 | ||||
| Expected Learner Actions | Modifiers | Triggers |
|---|---|---|
|
Request vitals from nurse |
Students ask for labs -> No IV fluids @ 8mins -> Nurse/Facilitator to prompt No lab request @ 8mins -> Nurse/Facilitator to provide labs/PoCUS |
Patient fully assessed (Hx and Px), incl. social Hx, + Labs + PoCUS |
| Physical Exam | |
| Cardio: Faint pulse, tachycardic, heart sounds normal | Neuro: decreased strength U and L extrem. Fatigues easily |
| Resp. Normal | Head & Neck: Normal |
| Abdo: Pain LLQ and RUQ, Guarding on palpation Tender diffusely Hepatomegaly |
MSK/Skin: Slightly jaundiced |
| Other: | |
HPI: Mali is living in the Zaatari refugee camp in Jordan, after being forcibly displaced from her home in Syria (or other country depending on SP). The camp is overcrowded, Mali is living in a small shelter with her partner Kash and two other families they do not know. Mali has been living in the camp for about one month, and has not had access to any medical attention until today. For the last three days she has been experiencing worsening abdominal cramping, nausea, and more frequent bowel movements. Her stool is loose and watery, though it is hard to tell if there is blood since they are sharing a pit latrine that is quite dark. It is warm in the camp, but she feels warmer than usual, and thinks she is running a fever. She has not eaten much in the last few days since her appetite is diminished. She has been nauseous and is vomiting as well. Today she woke up feeling weak, disoriented, and dizzy. Her partner Kash brought her to the mobile MSF clinic that you are volunteering in.
On exam, Mali’s abdomen is sore, and is tender to the touch, especially in the left lower quadrant and right upper quadrant. She has experienced some cramping, colicky pain diffusely across the abdomen, as well as some increased flatulence. It is worst in the right upper quadrant (“under my ribs on the right side”) and in the left lower quadrant. She has been nauseous for the last few days and there has been some vomiting. She has heard that others in the camp are feeling sick too, but hasn’t had the energy to find out more information about this.
Psychiatric: She is experiencing substantial stress from her recent move, as her family was sent to the Azraq refugee camp, located in Eastern Jordan. She has been having new, vivid nightmares for the last few weeks affecting her ability to sleep. These dreams are littered with images of the violence she witnessed while in Syria (or other country depending on SP). She has noticed that her mood has become lower and that she was becoming increasingly restless and anxious before the fatigue and this illness hit.
Context
1) Infrastructure and hygiene in the camp: Their drinking water comes from a well, bathroom access is a shared latrine, and access to cooking appliances to prepare and heat food is inconsistent.
2) Sick contacts: She has heard that others in the camp are ill, but she hasn’t had the energy to learn more about this
a) If students ask the Nurse: “Yes, there seems to be something going around, but we aren’t sure what.”
Screening: Hasn't seen doctor since she was a young child. No pap tests or other screening measures completed that she can remember
Vax Status: Can't remember which vaccines, if any, she's ever had
Social
Family - Family transferred to Azraq refugee camp in Eastern Jordan. Mali placed here with partner
Current Housing - Shared shelter with 2 families in Zaatari camp, Jordan
Nurse/Facilitator: "The patient looks dry and she is hypotensive. I think we might need to treat her"
| Patient State/Vitals - Unchanged | ||||||
| Rhythm: | HR: | BP: | RR: | |||
| O2SAT: | T: | GCS: | ||||
| Expected Learner Actions | Modifiers | Triggers |
|---|---|---|
|
State that they would hang fluid (NS, RL) and administer bolus |
Right before Case End ⇒ Stool C&S comes back positive for entamoeba histolytica |
Fluids provided and social concerns about moving to Canada start to be addressed ⇒ End and go to Debrief |
Facilitator Notes: Increased WBC points to a sign of infection, decreased hemoglobin suggests an anemia potentially due to a bleed, decreased production, or increased destruction of RBCs. Eosinophilia suggests parasitic infection. Low potassium due to diarrhea and ++ fluid loss. Biliary values: suggest insult to liver. ESR suggests an underlying inflammatory process.
Notes: Well-circumscribed abscess containing multiple hypoechoic collections and heterogenous material with similar echogenicity to surrounding liver parenchyma
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
|
Phase |
Objective |
Task |
Sample Phrases |
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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
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“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
|
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
|
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?” |
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Analysis |
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“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 |
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“So, what we’ve talked about in this scenario is…” “What have we agreed we could do?” |
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Application |
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“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….? |
||
|
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:
