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Exploring the Experiences of Nursing Students during Debriefing: A Qualitative Study

Wafaa Elarousy*, Jennifer de Beer, Hend Alnajjar

College of Nursing, Jeddah, King Saud bin Abdulaziz University for Health Sciences, KSA

Abstract: Background: Debriefing is a process involving the active participation of learners, guided by a facilitator or instructor whose primary goal is to identify and close gaps in knowledge and skills. It promotes understanding and supports transfer of knowledge, skills and attitudes with the focus on safe and high quality patient care. Hence, the aim of the study was to explore the experiences of nursing students during debriefing. Methodology: The study was conducted at the College of Nursing – Jeddah, King Saud Bin Abdulaziz University for Health Sciences. A qualitative research design was used which included convenient sampling of nursing students who were enrolled in clinical courses. Four focus groups were conducted until saturation was reached. Focus groups were recorded, transcribed verbatim and data analysis followed a content analysis approach. Results: Three main themes emerged: facilitators, barriers and the way forward. The participants within this study highlighted that learning from shared experiences of colleagues was a factor that promoted a positive attitude towards debriefing. Long clinical days was the most prominent barrier to debriefing with debriefing sessions focusing on the same content that was discussed in the clinical area was identified as the next barrier. Hence nothing new was added in order to promote learning during debriefing. Conclusion: This study affirmed many of the common, frequently cited advantages and disadvantages of the debriefing process. There is certainly an opportunity for the process to be improved by using evidence-based methods that will achieve the same or better results.

Keywords: debriefing, qualitative study, student nurses

Received January 21, 2019; Revised February 23, 2019; Accepted March 23, 2019

Citation: Wafaa Elarousy, Jennifer de Beer, Hend Alnajjar, Exploring the Experiences of Nursing Students during Debriefing: A Qualitative Study. American Journal of Nursing Research, 7 (3). 310-315. January 2019. doi:10.12691/ajnr-7-3-11

1. Background

Debriefing is a process involving the active participation of learners, guided by a facilitator or instructor whose primary goal is to identify and close gaps in knowledge and skills [1,2]. It promotes understanding and supports the transfer of knowledge, skills and attitudes with focus on safe and high-quality patient care [3]. Through debriefing, the healthcare team can reexamine the clinical encounter to foster the development of clinical reasoning, critical thinking, judgment skills, and communication through reflective learning processes [4]. Further to this, Decker et al [3] reported that all effective simulation sessions should include a planned debriefing session aimed towards promoting reflective thinking with the intention to assist learners in examining the meaning and implications of actions taken during a simulated experience. Reflection includes assimilation of knowledge, skills and attitude with pre-existing knowledge. It can be taught by active involvement in a realistic experience and guidance by competent facilitators [3].

Debriefing is identified as a post-experience teaching and learning exercise that is vital to learning experiences [5]. It enables the students to learn from their mistakes [6], provides them the opportunity to reflect on their experiential learning exercises and to hypothesize how they might perform differently the next time [7]. In addition, it enhances experiential learning and is an essential component of simulation training [8]. Furthermore, debriefing techniques can enhance skills and improve the quality of patient care [9].

There are numerous research studies that support the benefits of using debriefing. A Quasi-experimental repeated measures survey of baccalaureate nursing students’ simulation training with debriefing was conducted by Bambini, et al (2009) as cited in Cant and Cooper [8]. These authors reported a significant increase in skills in students after a simulation training session with debriefing (Bambini et al, 2009 in Cant & Cooper, [8]). Similarly, Mangone et al [10] conducted a qualitative study using focus groups to explore the effectiveness of debriefing sessions for new graduate nurses and trainee enrolled nurses. The results demonstrated that debriefing sessions provided nurses with psychosocial support in the clinical area.

There are many important factors that contribute to the success of debriefing. One of these factors is the facilitator. The facilitator has the responsibility to make the participants active and responsible for their own learning whilst addressing important learning issues during the debriefing process. The facilitator should aim to direct and guide during the debriefing process rather than to lecture. In addition, the facilitator should use a non-judgmental approach. The facilitator needs to expand the role of the participants from the traditional passive role to a role that allows participants to critically analyze their own performance retrospectively [6] through a psychologically safe environment [11]. Furthermore, the facilitator should assist in sharing critical judgments during debriefing which is an essential part of learning in simulation and debriefing [11]. Another factor that contributes to success in debriefing is the physical environment in which the debriefing is conducted. The debriefing room should be comfortable, private and arranged in a circular fashion [6].

1.1. Conceptual Framework

Kolb’s Experiential Learning model can also be incorporated into and provides a framework for the debriefing process. Kolb’s four stages are (a) concrete experimentation, (b) reflective observation, (c) abstract conceptualization, and (d) active experimentation [12]. The first stage is the simulation session (concrete experimentation) and the debriefing process starts with the second stage which is reflective observation as the students start to express what has happened from a variety of perspectives e.g. own feelings; the student’s and groups view. The third stage which is abstract conceptualisation is when the students keep the process of reflections within a theoretical understanding. Finally, a new understanding is developed by the students that guide them should they be exposed to similar situations in the future.

1.2. Significance of the Study

The College of Nursing – Jeddah (CON-J) was established in September 2006 and it is located in the Western Region of Saudi Arabia. All clinical nursing courses include simulation sessions and clinical placements, starting at 7am and finishing at 5pm, once a week per course. The clinical experiences either in the hospital or through lab simulation sessions include an hour of debriefing. These simulation sessions are evaluated at the end of each semester by the Quality Department. Stemming from this evaluation, survey of the Fall semester of the academic year 2015-2016 included negative feedback by students related to debriefing sessions which included “The debriefing sessions were time consuming”, “The debriefing sessions were energy consuming”, “Students were very tired during debriefing time”, and “Unnecessary because the doctor already had discussions with students in the ward”. It is evident through empirical research that debriefing is important in nursing students learning experiences. Cantrell [13] investigated the benefit of a structured debriefing session on students' learning after the students completed three pediatric-based clinical simulations and the findings from the discussion of the debriefing session suggests that students have a strong need for debriefing immediately following the conclusion of each simulation session, in order to help them decompress and integrate the experience into their knowledge base. It is within this backdrop that the study aimed is to explore the experiences of nursing students in debriefing through a qualitative design.

1.3. Research Question

What are the experiences of nursing student during debriefing?

2. Methodology

2.1. Study Setting

The study was conducted at College of Nursing – Jeddah, King Saud Bin Abdulaziz University for Health Sciences. The clinical curriculum uses debriefing as one of the teaching strategies.

2.2. Study Design

2.2.1. Research Paradigm

Research paradigms provide guidance to the researcher’s perspective with regard to the phenomenon being studied. The belief a researcher holds is reflected in the way the research is designed and how data is collected, analyzed and presented [14]. However, it is important to reflect on the ontological and epistemological foundations of the study in order to understand the research paradigm and design. The researchers assume a relativist ontological position, claiming the world to be consisting of multiple individual realities influenced by circumstances [15]. Epistemologically; the researchers are constructivist in nature. Constructivism gave the researchers an opportunity to understand the phenomenon of debriefing with the benefit of experiences from the participants’ co constructing meaning and ultimately generating meaning from the data that is grounded in the participants and researcher’s experiences.

A qualitative research design was used as the researchers believed that qualitative research has several hallmarks. It is conducted in a natural setting, involving rich descriptions of human behavior and opinions. There is also the allowance of multiple realities that individuals construct in their own environment which is keeping in line with the focus of this study involving the phenomenon of debriefing.

2.2.2. Sampling and Realization of Sample

A convenience sampling technique was used to recruit nursing students who were enrolled in clinical courses that included simulation sessions and hospital clinical training. In addition only students who were willing to participate were included in the study. Data collection was done by four focus groups until saturation of information was achieved. Focus groups were conducted in a private space, was audio recorded with the permission of participants and lasted between 45-60 minutes.

2.2.3. Data Analysis and Management

Data collection and analysis in this study occurred simultaneously so that the search for themes and concepts began from the moment data collection began [16]. Using the recorded interviews and transcription verbatim, analysis was done using content analysis.

All recordings were downloaded on a computer protected by a password and labeled using participants’ pseudo details and interview date with back-up copies stored on a memory stick. The data will be destroyed after a period of five years.

2.2.4. Academic Rigor

Trustworthiness

The criterion that was used in this study was outlined by Guba and Lincoln [17] and described by Polit and Beck [16] as the gold standard for qualitative research. Trustworthiness is the degree of confidence in qualitative research data which is assessed using the criteria of credibility, transferability, dependability and confirmability.

Credibility

This study employed member checking by giving feedback to participants to make sure that data interpretation was a true representation of their views and realities. Guba and Lincoln [17] considered member checking as a crucial technique to establish credibility of qualitative data.

Transferability

Transferability in this study was achieved by providing a rich and thorough description of study processes also known as thick description. Guba and Lincoln [17] note that the responsibility of the researcher is to provide sufficient descriptive data in the research report for consumers to evaluate the applicability of the data to other contexts.

Dependability

Refers to the stability of data over time and over conditions [16] and this was achieved by giving a detailed methodological description to allow for the replication of the study [18].

Confirmability

Inquiry audit used to enhance dependability will also be used in this case. Confirmability is the objectivity and neutrality of the data which ensures congruent opinions between two independent people about the data’s accuracy, relevance or meaning. Collection of research materials and documentation such as raw data, notes from member checking sessions, reflexive notes were done to allow an independent audit.

Ethical Considerations

The researcher submitted the research proposal to the Research Unit at the CON-J for review and a written permission to conduct the study was obtained. All the participants were fully informed about the research purpose, the nature of the study and indicated their willingness to participate in the study by signing a consent form. Participants were also informed about their right to withdraw from the study at any time.

Confidentiality was ensured by keeping participants’ personal information confidential and all research information was handled by the research team only for the purpose of the study.

3. Findings

3.1. Realization of Sample

Four focus groups were conducted with 5-6 students per each focus group. The average age of participants were 23 years and included students from different clinical courses.

Three main themes emerged: facilitators, barriers and the way forward with subthemes as depicted in the table below:

Figure 1. Summary of the themes and subthemes

3.2. Facilitators

The participants within this study highlighted that learning from shared experiences of colleagues was a factor that promoted a positive attitude towards debriefing. Participants expressed that sharing of experiences from within the clinical area equipped them with the knowledge to enable them to deal with a situation should they be exposed to it. This is expressed by the following interview excerpt:

“Also, when I listen to my colleague’s stories and how they deal with their patient, I also get benefit if I have the same patient for the next week or the other week. I know how to deal with it”.

“Yes and you can learn from this if I have the same experience, I am ready to deal with the situation, so sometimes if it is bad communication or if there is conflict and one of your colleagues express this experience, this will make you ready for facing this experience”.

Further to this, participants expressed that hearing from colleagues experiences within a particular rotation provided them with some insight into what to expect when it was their turn to be exposed to that particular rotation or area:

“For example if I am in surgical ward and after two weeks, I will be in oncology or medical, so I can get an overview from other students if they were in surgical ward … so I can take the idea what I will be exposed to”.

“I will tell my colleagues about my experience and also, we will share the experience like what was the procedure she was doing in the ward 8 and what procedure I did in ward, when we do the shifting, we already know what procedure we will have to do and what the medications we will get and what mistake she did so that we can avoid it.”

In addition shared experiences also created an avenue for student to learn from their colleagues for situations that they might never be exposed to:

”In maternity if I go in L&D, I did not see any cesarean delivery for all the rotations that I went in L&D and my colleagues saw the cesarean section, so I can hear from their experiences”.

“If we have an interesting case and we did not have the chance to see what happened after that, we can ask our colleagues and we can have the new information for example and how they deal with the patients in their cases.”

Participants expressed that debriefing provides an opportunity to track the progress of the patient. During clinical rotations, participants spend a period of eight hours with a patient and are not given an opportunity to know the outcome of the patient. However, as students are rotated within the same areas, participants expressed that debriefing provides an opportunity to know the outcome of the patient by hearing their colleagues talk about the same patients within the debriefing session. This is highlighted in the statement below:

“So, during debriefing you are oriented about ….if there is improvement in your patient or not”.

Moreover, participants reported that debriefing gave them a chance to express their feeling about their clinical experience.

“Expression of feeling, for me....once, I saw a neonatal resuscitation and I was so overwhelmed about it. So, when we went to the debriefing and talked about it, I felt more comfortable because the other students felt the same thing when you tell them that for the first time I saw neonatal resuscitation.”

Lastly under the theme of facilitators, participants expressed that debriefing promotes opportunities for self-study. When participants are exposed to new information within debriefing such as new diagnosis and treatment, it promotes an inquisitiveness, which lends an opportunity for participants to enquire by further research:

“For me the debriefing…when I hear a new procedure or a new case, I go home and research for it. This will ……… raise your attention about it”.

“Debriefing allows you to search and read about the new procedure and the new cases”.

“Yes, that has happened to me once when I saw a child. He just came to the hospital because he had watery diarrhea and they did not know what the reason was, so I searched about that a lot and study about it.”

3.3. Barriers

Long clinical days were the most prominent barrier to debriefing. Participants verbalized that spending many hours within the clinical area created physical tiredness when it was time to debrief. Typically participants would spend about eight hours within the clinical area. All participants were enrolled in more than one clinical course which meant that some participants had more than two clinical days per week. Spending a long time within the clinical area created as sense of physical tiredness that made debriefing difficult:

“Some days I feel tired, maybe because we have worked the all day with the patient, so I feel tired and I do not want to share the information”.

“I am tired …, but I cannot express my feeling, I cannot share. I cannot discuss”

“Because when we come to the college, we feel more tired and we are exhausted from the clinical day”.

“Sometimes, the teacher is forcing the student to talk.”

In addition, participants verbalized that they felt distracted by paperwork that was necessary after each clinical day that prevented them from having an effective debriefing session:

“Everyone has to fill the paper of the clinical in the debriefing time. To listen to our colleague and at that same time to fill the paper” .

“Progress notes, blood chart, case study....... Yeah, because we will have to submit it at the end of the day and don’t have time to document it.”

Respondents expressed that one a common barrier for debriefing is that that during debriefing no new information was translated from the clinical area during the debriefing discussion. Participants reported that debriefing sessions included that same content that was discussed in the clinical area and nothing new was added in order to promote learning during debriefing:

“Because in each group, they are talking about what they did in the hospital, but there is nothing to make me learn or improve my experience or like that. It is only stories they are talking about”.

“Repeating the same information that we have already covered and we did it in the hospital”.

3.4. The Way Forward

Although the college and the hospital are within the same vicinity, students used buses to move from the hospital to the college with their instructors (3 minutes by bus) to complete the debriefing. One of the themes that emerged from the study was the ‘context of debriefing’. Participants expressed to have the debriefing earlier within the hospital context instead of moving to the college. Having the debriefing sessions earlier and within the hospital meant that participants will not be tired and will be able to concentrate:

“Change the place of debriefing ... to be in the hospital, Yeah, because it’s fresh, we don’t have to come back to the college and do debriefing.”

“Mainly because we still concentrate while we are in the hospital environment ……”

“At the end, from 2-3, in the hospital, because we will get tired.”

“Make it early in the hospital; one hour is enough, for specific incidences. Interesting cases, not what is happening always in the hospital.”

Further, participants suggested to link theory with practice ensuring that the lectures for a certain topic are covered before being placed in the clinical area where patients with the topic related diagnosis are housed:

“We observed patient that they have a case that we learned either in the skills labs or theory. So we saw it in actually. For example, we see the disease then we take the lecture, so we connect it to each other. The lecture first then the disease.”

4. Discussion

As evidenced by this qualitative research study, there is a clear need to better understand the factors that influence students’ perceptions of the debriefing process. Ultimately, as described, debriefing is a valuable tool during nursing education to promote learning [3]. Therefore, finding ways to translate this value and ensure it is perceived as an asset, as opposed to a hindrance, will be important for nursing students’ progress. This study finding revealed that students do perceive some of these benefits. In addition, learning from shared experience is frequently cited as advantageous to learning, and acknowledged by many nursing students within the literature, as opportunities to reflect, express emotions and monitor personal professional development [19,20]. However, as revealed by this study, this is seemingly being counterbalanced and outweighed by barriers such as high workloads, time-consuming tasks like completing paperwork, and a lack of new information being elicited from the debriefing process. In turn, these barriers then negatively impact upon perceptions of the process and seemingly detract from the idea of debriefing as a valuable learning tool for nursing education. This is also highlighted by concepts within the theme ‘The way forward’, suggesting that altering the context and timing of debriefing, while creating strong links between theory and practice, could be highly beneficial in altering students’ perceptions. Accordingly, these barriers are also well-evidenced in literature, suggesting that they frequently affect nursing students and obscuring their perception of the benefits of debriefing [21,22].

However, some of these barriers are likely easily overcomed. For example, the use of simulations that do not predominantly rely on excessive paperwork is frequently studied in research and reported to be effective in achieving the desired outcomes of the debriefing process for nursing students. Moreover, such a method of delivery is noted by participants to be aligned with the facilitators highlighted in this study [22,23]. For example, high-fidelity simulations that are guided by competent, experienced nursing facilitators are said to result in environments that promote reflective learning and emotional processing [22]. Those delivered via focus groups, when compared to traditional methods of debriefing such as those that are paperwork-based, are said to deliver comparable or improved learning among nursing students [23].

Furthermore, high workloads, time demands and failure to realize the links between theory and practice elicited by the debriefing process should likely have been anticipated. Nursing, both as a profession and a course of education, is well-acknowledged to be highly stressful and demanding for nursing students, with burnout as a common phenomenon in pre-registrants and registrants alike across international settings [24,25]. Therefore, it seems rational to assume that recognizing these risks and alleviating them where possible, through learning processes that do not exacerbate such conditions, can only be advantageous. Moreover, effective debriefing processes have been reported to be efficacious in reducing rates of burnout and levels of stress among nurses, especially following highly stressful clinical events [26,27]. This further emphasizes that improving the current debriefing process may not only yield significant benefits in directing learning, but also have far-reaching implications for the profession as-a-whole, combating some of its major problems today [28].

Additionally, a theory-knowledge-practice gap is another well-demonstrated phenomenon said to impede nurses’ ability to deliver best practice, and seemingly propagated by the current debriefing process. It is said to be a major challenge to learning among nurses and, admittedly, is problematic to overcome [29]. Perhaps using paperwork during the debriefing process negates a highly structured protocol that results in students lacking the freedom to realize the links between theory and practice. Interestingly, stress and anxiety, exacerbated by the current process, is said to be a primary cause of such ambiguity and absence of realization [29]. Alternatively, simulation-based debriefing may offer greater freedom and opportunities for facilitators to direct and support students in achieving this link between theory and practice, transforming the process into one which is more meaningful to their clinical experiences and learning [22,23].

5. Limitations

The use of one nursing college and only nursing students within the university is seen as a limitation.

6. Recommendations

Consequently, it is recommended that there should be future work that investigates alternative methods of debriefing that promote the facilitators highlighted in this work, while also overcoming the barriers it has revealed. This should include a more in-depth exploration of the themes raised in this work, using larger sample sizes across multiple settings. Simulation-based debriefing processes, conducted within focus groups and led by an experienced nursing modulator, are recommended. These could be initially piloted with student feedback used to assess students’ perceptions of this change. However, there must of course be a process of monitoring the impact on students’ learning and development. Ultimately, the existing research certainly suggests that such an alternative approach may not only be preferable for students, but also result in substantial improvements to professional education. Furthermore, research including registered nurses, becoming a consistent feature of continuous professional development long after registration is advocated [28]. Moreover, simulation versus debriefing that is heavily reliant on paperwork may also address some of the significant concerns facing the nursing profession today, alleviating stress and the occurrence of burnout. Therefore, this research strongly recommends the adoption of a piloting scheme for high-fidelity debriefing and subsequent monitoring. Lastly, research around debriefing should be replicated using other students and colleges within the Health Sciences discipline.

7. Conclusion

This study affirmed many of the common, frequently cited advantages and disadvantages of the debriefing process. However, the study, coupled with other findings, demonstrates that there is certainly an opportunity for the process to be improved by using evidence-based methods that will achieve the same or better results.

References

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