Simulation debriefing based on International Nursing Association for Clinical Simulation and Learning standards may take place three hours or more after students participate in their scenario (INACSL Standards Committee, 2016). The time lapse between simulation activities and end-of-simulation debriefing is often too far removed from the activity, possibly causing cognitive overload and loss of information for the learners. According to Sweller et al. (2011), extraneous or cognitive load should be minimized by decreasing the amount of mental load occurring simultaneously in working memory. Waiting for feedback, correction, and debriefing increases cognitive load.
To mitigate erroneous thinking and resolve clinical practice errors that occur during high-fidelity simulation, there is a need for timely reflection-in-action, guided deliberate practice, and corrective instruction. An augmented approach, or clinical pause, creates timely opportunities for faculty and students to utilize Caputi's (2018) thinking skills to construct mental models and clinical reasoning congruent with quality nursing care.
Clapper and Leighton (2020) described how pausing and reflecting during the simulation experience may illuminate concepts that are key to learning outcomes. Their reflective pause is based on the work of learning theorists Argyris and Schon (1992, as cited in Clapper & Leighton, 2020), and it occurs as a single event or multiple times during the simulation. The reflective pause helps learners understand the rationale and effects for their decisions during the experience. Clapper and Leighton elaborate that reflecting during the simulation allows for unlearning wrong knowledge and skills. Furthermore, this format allows the facilitator to change course if the simulation is moving away from the learning objectives.
In contrast, during the clinical pause that we describe, a designated faculty member observer walks students through Socratic questioning and sequential clinical reasoning based on Caputi's (2018) thinking skills and Tanner's (2006) clinical judgment model. Although reflection is incorporated, it is one of many strategic elements. Tanner reviewed more than 200 studies on how nurses clinically reason and form clinical judgments, describing the sequential process as noticing, interpreting, responding, and reflecting. Embedded within the graphic of her model is reflection-in-action and reflection-on-action. Caputi (2018) extols this model for teaching nurses how to think and provides questions to help students develop thinking skills and clinical judgment. Both Caputi and Tanner provide guidance for how to facilitate the clinical pause. The proposed clinical pause does not replace traditional reflection-on-action debriefing; it supplements it.
Prior to our implementation of the clinical pause, student comments from written simulation feedback included themes of uncertainty and lack of confidence. Comments about areas for improvement included the following: 1) "Maybe having a discussion/planning time where the couple [of students] could figure out an efficient care plan before entering the room. I think this would help me feel more prepared and confident going in to the simulation along with additional situational learning"; 2) "Debrief afterward was positive overall, but lacked enough feedback, explanation, etc."; 3) "I felt very scatter brained and it caused small things to slip my mind"; and 4) "It was harder for me to pay attention in the debrief as it was later in the afternoon and we may have been hungry and the conversations were beneficial but hard to sit and listen to length wise as we were tired."
CLINICAL PAUSE IN SIMULATION
The aforementioned Caputi (2018) model for teaching thinking in nursing guided our clinical pause process. Caputi's model, partially based on Tanner's (2006) clinical judgment model, draws out students' thinking processes, knowledge base utilization, preconceived assumptions, and contextual thinking-in-action. Through meaningful questioning, faculty assist students to improve critical thinking, promoting clinical judgment development.
We implemented the clinical pause strategy in spring 2020 in a junior-level baccalaureate program. The high-fidelity simulation centered on a postoperative patient with perfusion, ventilation, and mobility complications. Eight students participated in a four-hour unfolding simulation composed of four 20-minute progressive scenarios (two students per scenario). Prior to beginning the simulation scenario, a faculty-facilitated prebriefing session was conducted with all eight students utilizing six key questions written on a whiteboard: 1) What is known? What do we notice? 2) What is not known and how could we find that information? 3) What does/what could the data mean? 4) What should be done? 5) What was the effect of our actions? 6) What is influencing our thinking? Why do we think what we think? These key "thinking" questions were used to collect observational notes and guide the clinical pause discussions throughout the entire four-hour unfolding simulation scenario.
Immediately following the prebriefing, the first student dyad entered the simulated patient care environment and began a 15-minute scenario; the remaining six students and faculty facilitator observed and took notes in response to the six key questions. After the scenario, the student dyad rejoined the faculty member and classmates, and the clinical pause discussion began. This process was repeated until all four student dyad groups had completed a simulation scenario. Each clinical pause duration was approximately 20 minutes in length.
The clinical pause consistently began with positive feedback, validating correct thinking and actions that were demonstrated by the student dyad. Next, the faculty member solicited responses from all students, focusing first on Caputi's (2018) model while also incorporating components of Tanner's (2006) model. Specific to Tanner's work, faculty members utilized terminology such as noticing, interpreting, responding, and reflecting. The inclusion of the observers in the clinical pause aligns with Johnson's (2020) analysis that merged observational and experiential learning theories for application to simulation. Johnson suggests that observers learn as much as active participants during simulation if they are properly cued and engaged.
Student and faculty observations were written on the whiteboard under the appropriate question heading and remained on the whiteboard throughout the entire simulation session. The clinical judgment questions were supplemented with Socratic questions that probed assumptions, perspectives, implications, and consequences of thinking. The Socratic questions were asked to both the student dyad and the entire simulation group. For example, faculty asked the following: 1) What are the most important client problems at this time? Why? 2) You seem to be assuming that your client's current condition is caused by _______. Tell me more about that. 3) What are other possible reasons for _______? What are some other alternatives? Does anyone view this differently? 4) What do we expect to happen next? Why? Subsequent observational notes for the remaining student dyads were grouped under the same clinical judgment headings and again were expanded upon as needed.
STUDENT AND FACULTY PERCEPTIONS
The clinical pause was not evaluated utilizing research methodology. Instead, we collected and evaluated student perceptions employing quality improvement strategies. Students (n = 42, 84 percent) completed an anonymous faculty-developed online survey, providing narrative responses to the prompt, "Please provide comments or suggestions about the simulation experience." Student comments suggest the clinical pause facilitated timely knowledge construction, contextual thinking, and clinical judgment. The following text segments are reflective of the whole: 1) "I really like the format of doing a scenario in simulation and then pausing to talk about it and plan for the next scenario. It's a GREAT change to simulation." 2) "I really think sim lab has improved a lot since last semester[horizontal ellipsis]I really like debriefing and pausing after every group goes." 3) "I love the "pause" in between each pair for simulation. This allows me to really process and think through what care we are giving, and what the priorities are in the next section of the simulation." 4) "It's helpful to be able to talk through the whiteboard as a whole sim group rather than just as pairs. It increases learning and you can hear so many more perspectives."
Anecdotal faculty comments aligned with student narrative comments. Specifically, faculty perceived the clinical pause approach provides timely feedback, reflection-in-action, and opportunities to enhance students' thinking skills. For example, during each clinical pause, student dyads reported assessments, interpretations, hypotheses, interventions, and patient outcomes associated with their specific simulation scenario to the entire simulation session group. Faculty provided positive feedback for the student dyad, balanced with probing questions to draw out thinking processes, challenge assumptions, solicit differing perspectives, and hypothesize. The timing of the clinical pause promoted rich discussion and robust learning based on recent recall rather than remote recollection.
IMPLICATIONS
The clinical pause innovation raises recommendations for nursing research. A quantitative pretest and posttest research design could measure the relationship between clinical pause strategies and the student's ability to effectively prioritize patient care needs. A qualitative phenomenological research design could generate themes providing rich meanings of clinical pause strategies from students' lived experiences.
REFERENCES