Development of an instructor guide tool: ‘Three Stages of Holistic Debriefing’

Objective: to describe the development of an English and Brazilian Portuguese Holistic Debriefing Tool focused on nursing educator to promote a reflective learning. Method: a methodology study, with three phases: integrative literature review; tool development and review of a panel of nursing experts. The literature review tracked a systematic process. For the tool development were used literature review results, Lederman’s Debriefing Process and Zabala’s learning framework as theoretical referential to promote a reflective learning in High-Fidelity Simulation. The panel of nursing experts analysed the quality of the tool. Results: literature review evidenced gaps about educator pedagogical preparation and indicated no holistic debriefing tool exists which captures formative and summative aspects of debriefing guidance to assist the educator to debrief. Debriefing tool was purposed with two pages: first page were recommended how conduct debriefing and second page is a questions guidance. The tool evaluation was undertaken for a total of three modifications for congruence and concept reader clarity. Conclusion: it was proposed a holistic debriefing tool focused on nursing educator. This study provides an overall picture of the process to promote a reflexive learning in High-Fidelity Simulation and to contribute to formal nursing educator training to apply best pedagogical practice.


Introduction
In the last decade, High Fidelity Simulation (HFS) has been used extensively in nursing education as a resource for teaching and learning. HFS is defined as learning activities which can replicate the practice setting in order to achieve specific educational goals and attend to the social requirements of maintaining patient safety (1) .
Debriefing is an essential component of all simulation experiences (1)(2)(3)(4) . It is defined as a pedagogical method whereby students are guided by a facilitator through a reflective thinking process thus assisting them to connect theory to practice and to understand concepts within the simulation scenario (1,3) .
Debriefing has a number of benefits to nursing education including reflective thinking process thus assisting nursing students to connect theory to practice (5) ; an important step to engaged students in meaningful learning (6)(7) ; to support students in deconstructing the learning activity and then synthesize the experience to reinforce the learning activity for future recollection (8) ; to facilitate experiential learning to develop/hone skills, to reduce negative feelings and to connect the simulated activities to real-life clinical situations (2,(5)(6) .
Without this reflection (debriefing) stage, the effectiveness of the simulation activity can be greatly diminished and hinder the students' assessment of the activity and its connection to previously built learning while in their programs of study (2,(5)(6)(7)9) .

As a central and basic component of HFS debriefing
is universally accepted; however, is unclear how nurse educators are taught to apply best pedagogical practice (9)(10) . Despite the indicated value of debriefing to the learning process, particularly in nursing education, research remains poorly articulated (2,9) . There is a lack of evidence in relation to the ability of the educator/ instructor/debriefer to support, to guide, to observe, to evaluate and to direct actions, discussions and reflections of the student during the debriefing component of HFS.
It is imperative for the nurse educator to be knowledgeable in how to conduct debriefing, including consideration of best pedagogical practice (8)(9) . The question arises that for nurse educators, does utilization of a Debriefing Tool serve to provide relevant information to apply best pedagogical practice (11) in HFS, wich means the nurse educator has competency to facilitate learning, to brief supportive and immersive feedback and to promote effective communication?
Although some debriefing assessment tools (12) reflect core components of debriefing, they focus specifically on student perspective. Thus, there is a lack of consensus and an absence in the literature in relation to formalized resources targeting debriefing in simulation to assist the nurse educator to conduct debriefing which considers the best pedagogical practice and becomes an important ally for the development of nursing students' clinical acumen (7,(13)(14) .
Considering that simulation is utilized globally and the lack of best pedagogy is universal, the purpose of this paper is to describe the development of an English and Brazilian Portuguese Holistic Debriefing Tool focused on nursing educator to promote a reflective learning.
Therefore this tool in more than one language accommodates the usage of the tool in a global manner to be shared in many institutions with transferred applicability.

Method
A methodological study (15)  descriptors to PUBMED, and combination of them to VHL and CINAHL. The terms used were "high-fidelity simulation", debriefing, "education, nursing", "students, nursing" or "undergraduate nursing" or "graduate nursing student", "case studies", "health case", and In the second phase the tool was developed in accordance with the literature review findings, the theoretical referential of debriefing of Lederman (1992) (16) and attitudinal, procedural and cognitive learning process of Zabala (1998) (17) .
The framework of Lederman's Debriefing Process argues that debriefing is composed by three steps: "the systematic reflection and analysis (participants systematic self-reflective process about the experience through which they have just come"); "intensification and personalization (refocusing of participant's reflections onto their own individual experience and the meanings they have for them)"; and, "generalization and application (participants from their own individual experience to the broader applications and implications of that experience)" (16) .
The framework of Zabala (1998) sustains the learning process could occur in attitudinal, procedural and cognitive perspective, which are extrinsically connected, to one another. In addition, tool developers' approached with author proposes of grouping and join in teaching-learning activities or sequences of instruction, relations and communicative situations between teachers and students in order to socially and organize the group, distribute space and time (17) .
Depending on the focus and student educational levels of knowledge, the nurse educator must customize the simulation experience to entail one aspect of a learning modality, or the simulation may be leveled in complexity to include higher-level knowledge and skill application, which targets cognitive, attitudinal and procedural learning simultaneously (16)(17) .

Data collection was between November 2016 to
March 2017; draft number 10 was considered adequate to the expert's revision.

Results
At the literature review (phase 1), the first search resulted in 220 studies: 61 from Web of Science, 31 from VHL, 44 from PUBMED, 30 from Cinahl and 54 from SCOPUS, which was its abstract and/or full-text was read to analyze the attending of criteria inclusion; 31 primary studies were included which it is related to the debriefing process.
This study identifies while it is primarily faculty members who conduct debriefing, formal pedagogical preparation criteria is absent. Only one study focused on the role of the nurse educator in HFS debriefing including the promotion of best pedagogy. A study indicated that formative debriefing was conducted. Of the total, 16 studies indicated using tools (23 -12 studies indicated to use more than one tool) to guide or evaluate the debriefing process on student perspective, none of which was developed specifically to assist the nurse educator to conduct debriefing, including attending to particular learning processes such as attitudinal, technical and cognitive modalities.
As results of the second phase, considering developers' expertise as nursing educator/research who conduct/teach and lead HFS and debriefing, a framework is being purposing of holistic debriefing Rev. Latino-Am. Enfermagem 2020;28:e3229.
including formative and summative debriefing. Tool allows the nurse educator to guide the entire group (hand on HFS experience and group observation) to selfreflection and group reflection through all the simulation experience. Additionally it can also help the nursing faculty to improve their role as educators to conduct the debriefing incorporating pedagogical elements in its performance, through the use of a tool.

According with INACSL Standards of Best
Practice (20) , the HFS simulation process may occur with small groups to facilitate the formative evaluation, no more than 5 students per educator. For the purpose of this tool, authors define the formative debriefing as a reflection activity that must be performed by the nursing educator during the whole simulation process, considering that debriefing should be a continuous process of reflective thinking for nursing student learning and future decision-making.
This study is purposing a tool called 'Three Stages of Holistic Debriefing' within three stages, and suggested time for to complete each simulation stage, including the pre-briefing (Figure 1).

Three Stages of Holistic Debriefing Focused/Formative/Summative -Instructor Guide Debriefing Tool
Pre-briefing: Complete all pre set objectives prior to beginning of the simulation session • O instrutor estabelece um acordo com todos os participantes do grupo para promover um ambiente seguro, ou seja: respeito mútuo, confidencialidade, ética, um programa de tempo para cada atividade, objetivos de aprendizagem específicos, e fornecimento de informações para o próximo cenário de simulação .
• The instructor provides information regarding all of the equipment's functions, including mannequins (or standardized patient) and the role of each of the participants.

First Debriefing Stage: Immediate Student Self-reflection post hands on experience FOCUSED DEBRIEFING
• The instructor invites the student as (he) completes the hands on experience to reflect on affective, cognitive and procedural learning before opening up the discussion to large group discussion/reflection. (see part B for guidance question exemplars)   Rev. Latino-Am. Enfermagem 2020;28:e3229.

Discussion
Considering that facilitators should be adequately what they may learn. Also, Lederman (16) argues that (Here is a safe environment for everyone to learn, to share and discuss idea and to build knowledge together… It will not be used with an evaluation purpose) During group observation the instructor facilitates a review of the chosen concepts in terms of affective, cognitive and procedural needs.
(What aspects of the simulation experience are relevant to discuss based on best practice evidence) OR (What are some aspects of the simulation experience that can help the group to learn about …?) o Affective learning (As a group how were you feeling during the simulation experience process?) o Cognitive learning (As a group what do you think you learned or know/understand better now?) o Procedural learning (As a group how has this simulation experience and discussion helped you to develop your psychomotor skills? Why or why not? Allow reflection with the group to explore how they connect previous knowledge and apply to learning in the simulation experience.  Because student must be active during the learning, this study is purposing a formative debriefing. The expression "formative evaluation" dates from 1960s (24) to provides student's individual feedback of each stage of their learning process.
Debriefing as formative assessment is a highly interactive process in which skills and understanding are not simply dispassionately assessed by the instructor, but in which new insights are co-created in a dialogue between instructor and students (13) .
From author's teaching practice reinforced by scientific evidence, debriefing only at the end of the whole of the simulation may disinterest students and its influences in learning achievement. Stimulate the student actively participating in the pedagogical proposal improves higher levels of retention when trainees actively think about, analyze, and discuss what happened (5,23) .
The summative assessment occurs at the end of the training session, provides implicit feedback on where the student stands and may prompt changes in the students' knowledge or behavior, especially through the process of studying for the exam. Formative assessment, occurs throughout the training period and is tailored to the individual learner (13,25) , helps develop professional identity through the social interaction of learning conversations and helps to improve clinical skills or teamwork (25) .
Although in this study the authors believe the insimulation debriefing should be conducted throughout the simulation experience as a way to stimulate the active participation of the student (5) (hand on student and observation group), the tool proposal also allows the debriefer to perform the debriefing at the end of the simulation.
Depending on the physical structure and resources of the simulation center and the availability of safe and ethical spaces for the conduction of the debriefing, it is not possible to carry out the formative debriefing; students must feel they can externalize their knowledge and feelings without being judged and punish by colleagues or nursing educators (22,26) . For the use of the tool, this study advises: • Pre-briefing is an important step; it is part of simulation process and helps the student to feel comfortable with the experience.
• Guideline for formative debriefing. The educator must analyses what resources is available at simulation center to choose what the best way to conduct debriefing focused on best pedagogic practice.
• In situations where the formative debriefing is possible, the instructor may give voice for all students immediately after their hand on experience and simulates who does not feel comfortable to reflect loudly their experience.
• The guidance question exemplars are not mandatory; its could help especially novice educators.
• Reinforce with the group the importance of selfassessment and group reflection.
The limitations of the study are on the importance of carrying out prospective studies to follow the application of the tool with Brazilian and English-speaking nurse educator during the planning and execution of the HSF in nursing education to promote the best pedagogical Rev. Latino-Am. Enfermagem 2020;28:e3229.
practice for the training of competent and committed nurses with the global health.

Conclusion
In this methodological study, the authors proposed a new 'Three Stages of Holistic Debriefing' tool focused on nursing educator to promote a reflective learning.
This study provides an overall picture of development process as a resource, which promotes best pedagogy in HFS nursing education.
This study presents all the phases to develop an This tool can also be used to train nurses educators to use active methodologies and those who wish to include HFS in their pedagogical practice. Pedagogical managers should pay attention to this tool as an auxiliary resource to improve teaching practices in simulation labs.