Reflective Thinking in Healthcare Simulation

Healthcare simulation, a form of experiential learning and debriefing, is a critical component of simulation-based learning (INACSL, 2021; Nagle & Foli, 2021). Asking open-ended questions prompts learners to build on what they already know while exploring new content. This strategy helps learners synthesize new information, think critically about their performance, and identify knowledge gaps. Reflective open-ended questions help learners become more aware of how they acquire information and take more responsibility for their own education and training (Nagle & Foli, 2021). Clinical simulation is the perfect experiential learning tool for the development of reflective thinking and the simulated environment provides the required level of intentionality. This HealthySimulation.com further explains why reflective thinking is essential across medical simulation and provides insight into a useful framework.

In today’s world, simulation educators are busy being busy. They race through their day, bouncing from one activity or task to the next. Too often, they tell themselves that they are too busy to think; healthcare simulation educators just need to keep moving and keep doing. However, when they act without taking time to think about why they are doing what they are doing, clinical simulation educators tend to repeat similar actions in similar situations, eliciting similar results. If they want to produce different results, they need to spend time thinking about the why of their actions (Raelin, 2002). Healthcare simulation education needs to make time for reflective thinking.

Reflection is a metacognitive process that occurs before, during, and after situations, with the purpose of developing a greater understanding of both the self and the situation (Nagle & Foli, 2021). Reflection involves thinking about thinking, knowing what is and isn’t already known. When individuals reflect, they become aware of their thoughts, feelings, and actions and how they affect their behavior, as well as the behavior of those around them (Costa & Kallick, 2017).

Reflection also helps identify what is gained from an experience, making reflection a tool for self-improvement. Reflection is an active and dynamic process that keeps on developing and evolving as educators learn and respond to new experiences, situations, and information. Reflective thinking involves interpreting and evaluating experiences, deriving meaning from these experiences, and using them for problem-solving (Raelin, 2002).

One of the earliest theorists to consider learning through reflection was John Dewey, an American philosopher, and educational reformer. Dewey thought that reflection could be very useful in making sense of situations, particularly ones that are found difficult. Thinking about the experience, questioning why the situation occurred in a particular way, and considering ways healthcare simulation educators could change the outcome of the event produces learning.

The idea that individuals learn by doing (aka experiential learning) is only part of the story. If they stop there and do not spend time thinking about the decisions they made and the actions they took during the experience, they are leaving potential learning opportunities on the table, so to speak. “We do not learn from experience. We learn from reflecting on experience.” (Dewey, 1933, p.78).

Dewey realized the importance of reflection. The experience alone does not necessarily lead to learning; the experience is the reflection that makes sense of the experience for the individual, thereby making the experience meaningful. Each experience presents opportunities to build new knowledge, skills, and attitudes.

Reflecting on Reflection in Clinical Simulation

Reflection doesn’t just happen. Reflective thinking is a learned process that requires some degree of self-awareness and the ability to critically evaluate experiences, actions, and results. Reflection is about being conscious and aware of actions and their consequences. Reflection is personal and can be steeped in emotion. Critical reflection is one of the fundamental ways in which learners gain knowledge and improve. Practicing reflection helps learners develop a growth mindset (Coutts, 2021).

Experiential learning is a method of educating through first-hand experience, allowing skills and knowledge to be acquired outside of the traditional academic classroom setting. Learning is a process whereby knowledge is created through the transformation of experience. The learning is enhanced if guided reflection is included as part of the experiential activity (Peterson & Kolb, 2017). Guided reflection is the facilitated intellectual and affective activities that allow individuals to explore their experiences in order to lead to new understanding and appreciation.

Guided reflection is a facilitated process that allows the learner to integrate the understanding gained from an experience, in order to enable better choices or actions in the future. Guided reflection reinforces the critical aspects of the experience and encourages insightful learning, allowing the participant to link theory with practice and research (Lioce et al., 2020).

Debriefing is a facilitated dialogue with peers and clinical educators following a healthcare simulation experience. This conversation is the most effective approach to foster deeper reflection, critical thinking, and clinical reasoning. The goal of the debriefing process is to assist in the development of insights, improve future performance, and promote the transfer and integration of learning into practice (INACSL Standards Committee, 2021).

Debriefing develops reflective thinking in participants. Reflective thinking is the self-monitoring that occurs during or after the healthcare simulation experience, assisting learners in identifying their knowledge gaps and the areas in which they need further improvement. Reflective thinking allows participants to make meaning out of the experience, identify questions generated by the experience, and ultimately, assimilate the knowledge, skills, and attitudes uncovered through the experience with pre-existing knowledge (Lioce et al., 2020).

While there are many frameworks for structuring a debriefing session, the STAND UP acronym focuses on promoting reflection during debriefing, regardless of the model being used:

S – Situation: Describe what happened during the experience; ensure everyone is on the same page
T – Thoughts: Identify the thoughts, feelings, and reactions associated with the experience
A – Analysis: Make sense of the experience and figure out its relevance
N – Nonjudgmental Evaluation: Discuss what went well and what could be improved
D – Determine Future Actions: Decide how this experience will inform future performance
U – Understanding: Confirm and validate the learners’ takeaways from this experience
P – Plan: Develop a plan for putting this learning into action

When healthcare simulation educators STAND UP for reflection, they are not leaving reflection to chance; they are planning for and monitoring learners’ opportunities for reflection. To STAND UP for reflection means they plan for times when learners will deliberately engage in the act of noticing how their thinking is evolving and the effect this has on their actions.

Learning is a result of reflecting on experience. Through reflection, they recognize the benefits of particular patterns of action and thought. By recognizing these patterns and the impact that they have on outcomes, clinical simulation educators equip themselves to incorporate the more effective patterns into future situations. They are also able to refine or abandon the patterns of action and thought that do not yield the desired outcomes.

Maximizing the Benefits of Reflection During Debriefing

During debriefing, facilitators guide learners to reflect upon their simulation actions and experiences. This guided reflection is essential in influencing student learning and clinical judgment development. With reflection, learners gain insights, leading to improved clinical judgment, critical thinking, and behavior changes. Antecedents necessary for reflection include a safe, supportive environment, previous knowledge, time, and trust between the facilitator, peers, and learner. Eight variables that impact the development of reflective thinking during debriefing include:

1. Environment: Ensure the physical space is conducive for reflection. Minimize noise and distractions. Create calm spaces where individuals might be alone with their thoughts.
2. Interactions: During debriefing, learners’ honest dialogue with peers and facilitator promotes sense-making, resulting in cognitive adjustments and perspective reframing. Creating a safe space for sharing of reflections is vital. Learners need to be able to engage in genuine reflection, sharing their misunderstandings, without fear of embarrassment or ridicule.
3. Language: Learners benefit from learning a language that supports their reflective practice. This might be as simple as a set of questions the facilitator asks to guide the reflection.
4. Modeling: Learners need to see their instructors engaging in reflective thinking. Make opportunities to join with students in reflective practice so they can see what it looks like for an experienced learner.
5. Expectations: Be clear with expectations regarding reflection. Let learners know the time that will be allocated for reflection and the desired outcomes of the process.
6. Opportunities: The same level of intentionality that goes into creating a healthcare simulation experience should be evident in the planning of reflection opportunities. When educators make reflection a routine part of healthcare simulation experiences, they promote the associated value. Scheduling time for reflection emphasizes the importance of this practice.
7. Time: Reflection takes time. Learners need to see the value in spending time thinking about their actions. If educators don’t engage students in reflective thinking after a healthcare simulation experience, they are short-changing their learning.
8. Learner-Centered: Attributes of learner-centered reflection are intentionally examining knowledge, skills, and attitudes; making sense of the medical simulation experience; thereby incorporating new information and behavior changes in future clinical situations. Consequences of learner-centered reflection include resolving knowledge gaps, correcting previous knowledge, developing a new understanding, and enhanced clinical judgment (Nagle & Foli, 2021).

Remember, reflection is a very personal experience. Facilitators should be mindful that the reflection that occurs during the debriefing session, can give learners an insight into their personality, and can reveal how they are feeling at a particular point in time. Exposure to these feelings can leave learners feeling vulnerable.

Reflective Thinking Leads to Reflective Practice

The reflection that occurs during the debriefing session is an example of Reflection-On-Action. Learners look back on the healthcare simulation experience to better understand the outcomes and how their thinking and actions contributed to those outcomes (Schön, 1983). Once learners gain proficiency at reflecting on action, the next step in their development as reflective thinkers is to reflect in action. Schön (1983) describes Reflection-In-Action as the ability to reflect on present experiences and activities to foresee how certain events or outcomes are happening, or are likely to happen.

This more advanced form of reflection allows those who engage in it to develop accountabilities and motivations for their actions and thinking. Costa & Kallick (2017) also acknowledged the need for reflection to span the entire learning experience. Instead of reflection being unidirectional, only looking back at an experience, reflection should be forward-facing, as well, considering possible outcomes of future actions based on prior experiences.

Reflective practitioner explores their actions and thinking before, during, and after an experience, considering the impact of their actions and thinking on themselves and others. Schön (1983) introduced the concept of the ‘‘reflective practitioner’’ as one who uses reflection as a tool for revisiting experience to learn from it and frame complex problems to better inform future performance.

Reflective capacity increases when individuals learn to reflect in action. Reflective capacity has been described as an essential characteristic of professionally competent clinical practice. In order to develop and maintain competence, learning effectively from experiences is vital. The fullest benefits of being a reflective practitioner are achieved when healthcare simulation educators plan for, notice, and reflect upon actions and then use the information gained to inform future choices (Coutts, 2021).

Experience plus reflection is the learning that lasts. If medical simulation educators genuinely value reflective thinking and want to produce reflective practitioners, they need to take a more proactive approach to develop the skill of reflection in learners. Instead of leaving reflection to chance, they need to build reflection into all learning experiences.

When simulation educators STAND UP for reflection and insist this critical component of the learning process be included in all healthcare simulation activities, learners will become more adept reflective thinkers. Learners will see the value of engaging in reflective thinking before, during, and after every learning experience. Reflection will be known as the glue that makes learning stick!

Learn How to Use the Reflective Pause in Clinical Simulation Debriefing to Maximize Learner Engagement

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      2. Coutts, N. (2021, January 22). Taking a reflective stance. The Learner’s Way. Retrieved August 20, 2022, from https://thelearnersway.net/ideas/2020/11/23/taking-a-reflective-stance
      3. Dewey, J. (1933). How we think: A restatement of the relation of reflective thinking to the educative process. Boston, MA: D.C. Heath.
      4. INACSL Standards Committee, Decker, S., Alinier, G., Crawford, S.B., Gordon, R.M., & Wilson, C. (2021, September). Healthcare Simulation Standards of Best PracticeTM The Debriefing Process. Clinical Simulation in Nursing, 58, 27-32. https://doi.org/10.1016/j.ecns.2021.08.011.
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         Nagle, A., & Foli, K. J. (2021). Student-centered reflection during debriefing. Nurse Educator, 47(4), 230–235. https://doi.org/10.1097/nne.0000000000001140
      6. Peterson, K., & Kolb, D. A. (2017). How you learn is how you live using nine ways of learning to Transform your life. Berrett-Koehler Publishers, Inc.
      7. Raelin, J. A. (2002). “I don’t have Time to think!” versus the art of reflective practice. Reflections: The SoL Journal, 4(1), 66–79. https://doi.org/10.1162/152417302320467571
      8. Ritchhart, R., & Church, M. (2020). Power of making thinking visible using routines to engage and empower learners. JOSSEY-BASS INC, U.S.
      9. Schön Donald A. (1983). The reflective practitioner: How professionals think in action. Basic Books.

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