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Right Action, Wrong Thinking: Dr. Dreifurst's Journey into Simulation Pedagogy

• Deb Tauber • Season 3 • Episode 106

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Dr. Kristina Dreifurst explains how her revolutionary Debriefing for Meaningful Learning (DML) model enhances clinical reasoning among nursing students through structured debriefing techniques that focus on the relationship between thinking and action. She shares her journey from using early Mrs. Chase mannequins as a nursing student to developing a pedagogical approach now utilized in over 500 nursing programs worldwide.

• Dr. Dreifurst's simulation journey began in the 1980s and gained momentum in 2005 when she received new high-fidelity mannequins
• An experience at Disney's "It's a Small World" attraction sparked insights about generational responses to mannequins
• DML originated during her PhD studies when her assumptions about simulation fidelity were challenged
• The "four square" approach examines right/wrong thinking paired with right/wrong actions
• "Right action, wrong thinking" is surprisingly common even among experienced clinicians
• Reflection Beyond Action component helps students transfer knowledge across different clinical situations
• Co-creating knowledge through Socratic questioning leads to better retention than lecture-style debriefing
• Simulation's role is evolving toward competency assessment in addition to being a safe learning environment
• Dr. Dreifurst is transitioning to a new role at Vanderbilt as senior associate dean for academics

Stay current with simulation education research and development as the field continues to evolve rapidly. Our students deserve the best that we can give them.


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The views and opinions expressed in this program are those of the speakers and do not necessarily reflect the opinions or positions of anyone at Innovative Sim Solutions or our sponsors. This week's podcast is brought to you by Beaker Health. Beaker Health is a user-generated and peer-reviewed community educational platform designed for healthcare organizations. We let your community connect and engage with one another freely and efficiently. Beaker Health, where dissemination and measuring impact comes easily. Welcome to the Sim Cafe, a podcast produced by the team at Innovative Sim Solutions, edited by Shelley Hauser. Join our host, deb Tauber, and co-host, jared Jeffries as they sit down with subject matter experts from across the globe to reimagine clinical education and the use of simulation. So pour yourself a cup of relaxation, sit back, tune in and learn something new from the SimCafe.

Deb Tauber:

Welcome to another episode of The SimCafe, and today Jerrod and I are here with Dr Kristina Dreifurst, and Dr Dreifurst is a distinguished nurse, educator and researcher, serving as a professor and the director of the PhD program at Marquette University in Milwaukee. However, in August she's going to begin working at Vanderbilt as a senior Associate Dean for Academics. So Dr Dreifurst is renowned for developing the Debriefing for Meaningful Learning DML model, a transformative pedagogical approach now utilized in over 500 nursing programs worldwide. This method enhances clinical reasoning and reflective practice among nursing students through structured debriefing sessions. So we are so grateful to have you today. Thank you so much for willing to be a guest, and why don't you share a few things with yourself and maybe your journey into simulation?

Dr. Kristina Dreifurst:

Thank you. It is great to be here with all of you today. My journey really started way back when I was a nursing student, which was a long time ago, because I'm one of those old nurses and I remember very clearly using an early version mannequin, Mrs Chase, and in fact we spent a lot of time as students changing Mrs Chase's outfits and her wigs, and way back in the 1980s. So really that's where I got the bug and then it was sort of latent for a while. But in 2005, I was a new part-time nurse educator. I was a clinical educator, I was working in the skills lab in a nursing program at the University of Wisconsin-Madison and we had received some new mannequins and I was absolutely fascinated. These were early, early high-fidelity mannequins and I just loved them.

Dr. Kristina Dreifurst:

And I had an opportunity in 2005 to go to Maryland and spend some time with the renowned Deb Spunt and she really showed me a lot about the versatility, the way that mannequins could enhance nursing education. So after that I had one other major sort of lightning experience. I had taken my kids in 2006 to Disney in Florida and we went through the. It's a small world event and if you've ever been to that event and I am not even sure if that event exists anymore, but they have all kinds of mannequins doing different things as you float by, and what I found absolutely fascinating is that people who were my age were just thrilled with the mannequins, and people who were younger were not so sure about them, and that really got me thinking a lot about how we introduce mannequins and how we make them real for students, how they can become actual patients that need to be cared for. So my journey really started way back at the beginning and it's been quite a ride.

Jerrod Jeffries:

It's a small world after all, yes and well said, I mean it is. I think there's right from where you began, back in 2005,. Of course, 20 years, that's quite the riding scene from very early conferences, quite the riding scene from very early conferences, of course, with your leadership over INASCL as well, and then into this new world of alternative realities that we're experiencing more and more at every conference we visit. So you've certainly been through a lot of different chapters.

Dr. Kristina Dreifurst:

Yes, I have.

Deb Tauber:

Yeah, I love the analogy of of it's a small world interactions. It's something that I overlooked, but I do recall being in there feeling the same magic and not sure what my kids were thinking.

Dr. Kristina Dreifurst:

Yeah.

Deb Tauber:

All right, now you have the DML. Why don't you tell our listeners about DML, how you created it and its widespread universal use, how that all came to be?

Dr. Kristina Dreifurst:

Sure, that's another journey in itself. So after my introduction to simulation and after I'd started working as a clinical instructor, I was still in practice, but I knew that I was going to probably move my career fully into education. And as I was doing that, I decided that I wanted to go ahead and get my PhD, because if this was going to be what I was going to do, then I wanted to be prepared for it and I wanted to do my doctoral work in pedagogical research. So I specifically sought out Indiana University at the time to go and get my PhD and I wanted to study mannequins and mannequin simulation and I wanted to study fidelity because I really thought that the more fidelity, the better the learning. That was what I came to do, that was what I really believed in. And I got there.

Dr. Kristina Dreifurst:

And in the first week in my program I met with my committee members and I told them I was all in and excited and I was going to study fidelity and simulation. And I remember sitting there and it was silent and they were kind of looking at each other and one of my committee members was kind of smirking his mouth, trying not to laugh out loud, and finally one of them said okay, and why do you think fidelity is so important? And I confidently said because I thought that the more the experience felt real, the better the learning students would have. And then another one said but haven't you ever done a case study and didn't you learn from a case study? And there was silence again and I was pretty deflated because I thought OK, so I've been here one day and already my ideas are out the door. Because, yes, I absolutely have used case studies, saw students learn from case studies, have learned myself from case studies. So clearly, clearly, learning isn't just tied to fidelity.

Dr. Kristina Dreifurst:

So then I had to find something else and so I dove into the literature, and again, this was at the time of just the very beginning, the early NLN Jeffrey studies. And what the piece that was the least understood and the least studied at that point was debriefing. And the model that had been adopted for those early studies really came out of the airline industry, the military, where debriefing really came out of the airline industry, the military, where debriefing really was focused on what went right, what went wrong and what would you do differently. And so, as I began to delve into this and I began to watch people all over the country in these very early times, try and do this debriefing. First of all, I saw from A to Z, from the best to the worst, as I moved around. But secondly, what I began to realize is that if students knew what they would do differently, they would have done it. So asking that really puts them on the spot. It's a form of feedback and it's a good way to do feedback.

Dr. Kristina Dreifurst:

But debriefing had to be more than and so I again delving into, as you do in a PhD program, delving into educational theory, delving into cognitive learning, how the brain learns, how we take meaningful, meaningful nuggets and then put them into action began my journey in developing Debriefment for Meaningful Learning, debriefing for Meaningful Learning. And I think the linchpin of this method really is that by using Socratic questioning and there's a specific piece of DML where Socratic questioning becomes the way that the debriefer and the learners interact, that the purpose of that becomes understanding what we call the four square. Was their right thinking right action. Was their wrong thinking wrong action. Was their right thinking wrong action. Was their wrong thinking right action. Because you see, as you watch somebody in sim or in traditional clinical or in practice, you're watching what they're doing and you're thinking, oh, that all looks right, that all looks right, that all looks right.

Dr. Kristina Dreifurst:

But as a debriefer, in using the Socratic method, it became more and more and more obvious how often it was right action, wrong thinking, right action, wrong thinking. And in probing that further it began it was like I didn't know what else to do. I saw somebody do this, it worked last time, and it became very, very clear that as an educator, we can't assume that just because students are doing the right thing, they're doing it for the right reason. And so DML really focuses on understanding the relationship between thinking and actions, and it's less about what's something methodically done correctly, what's the skill? It's less about the skill. Skills are important, how you integrate them into care of a patient, either in simulation or in practice, or it is important, but equally important is the thinking, the precipice.

Dr. Kristina Dreifurst:

Then, as people including in my work, but also other schools, as educators began using DML more frequently with students repeatedly, it became clear that thinking is also a form of muscle memory. That by doing this Socratic thinking, by challenging taken for granted assumptions, by really probing on the, it looked like what you did was right. Let's talk about how you came to that decision. How does this fit with this? How do you put this together? It became clear that we were teaching learners to think that way themselves, that, as they began to be comfortable with this probing and questioning and dialogue and explaining. This is what I saw, this is what it made me think about, this is what I remembered, this is what I did, that they began to do that themselves and they took that into practice, not necessarily hearing the voice of the debriefer, but subconsciously hearing. Does this make sense? Does it make sense right now? Is there something else I should be thinking about? And it really changed the metacognition, the clinical reasoning, the high thinking that learners who were using this debriefing over and over could demonstrate.

Deb Tauber:

And I love the fact that it's non-threatening debriefing for meaningful learning, just the whole. When you say it, it sounds like we want to learn about why you're thinking this way and disarms any learner from feeling threatened.

Dr. Kristina Dreifurst:

Well, that's our goal. That's our goal. I mean, I think there's always. Students are always nervous because they're always worried that they're going to be judged for what they did or for what they say. And it takes a lot to learn how to not be defensive when somebody's asking you about something that they thought you did correctly and to be comfortable with that. But that's also how you learn to be comfortable in practice asking yourself, boys, if something else I should be thinking about is that does this make sense for this patient? You know my inclination is to do this. Is there anything else? And that's, I think that really helps practice. That really helps us make good thinkers as clinicians.

Jerrod Jeffries:

Any activity or pattern you saw on some of these. I think you mentioned that debriefing or pre-briefing. Is there anyone just to use an example of the right action, wrong thinking?

Dr. Kristina Dreifurst:

I mean many, there's so many, I think. What surprised me the most, though? So debriefing for meaningful learning really began as a form of debriefing students, and particularly it began in nursing and we focused on thinking like a nurse, and then it morphed into other disciplines, using it both for interdisciplinary debriefing but also for other healthcare professions, adopted it in, then into practice, because now, then again, simulation went from being an educational model to being something that we did in practice. We see simulation centers all over in clinical settings, and what I expected as I started to debrief practicing clinicians, I expected that there would be less maybe negligible wrong thinking, right action, but in fact it really didn't seem any different, and that surprised me a lot, that even in practice, that we have to bring people back to what is the thinking behind this action and is there a match. And I was really surprised at how often even practicing seasoned clinicians, as we began to peel it apart, would demonstrate right action, wrong thinking.

Deb Tauber:

Yeah, right action, wrong thinking is a big thing. To be able to differentiate and recognize and, like you said, debrief around.

Dr. Kristina Dreifurst:

Correct, correct, and I think it helps us mitigate errors when we can really peel it apart. At what point did you come off the track? Did the thinking not match either the situation or the data or the information that led to the decision-making? Because, again, the action was correct and I firmly believe that you can get away with doing the right thing for the wrong reason a few times, but you cannot get away with doing the right thing for the wrong reason a few times, but you cannot get away with doing the right thing for the wrong reason all of the time. It's going to catch up to you.

Deb Tauber:

Absolutely, absolutely. Now, with all your experience, your vast experience in this, in actually developing a theory around it, do you have a favorite simulation story that you'd like to share with our listeners today?

Dr. Kristina Dreifurst:

parallel story. So way back 20 years ago, when I was a new clinical instructor, I had this experience happen. Like many of us in those days, we brought students in the night before to prep for clinical in the hospital and then they would come the next morning and care for a patient. And I had this experience. It was really in my professional role, one of those life-changing aha moments. So really good student. She had prepped to take care of an elderly patient who had been admitted in DKA and so, with lots of episodes of hyperglycemia and as often happened in community hospitals, during the night she began to fluctuate and they sent her to the ICU, off of the general care unit, to the ICU. So the next morning I got there early, realized that my student would need a new patient.

Dr. Kristina Dreifurst:

Again, this was a small community, rural community hospital where the adult med-surg patients would be on the main part of the floor, where the adult med-surg patients would be on the main part of the floor and then the last six rooms on the end would be for the pediatric patients. And so, as luck would have it, a young man had been admitted, a kid had been admitted. He was a newly diagnosed insulin-dependent diabetic and he had been diagnosed probably two months prior to his admission and he'd had a lot of education. His folks had had a lot of education, but he was still having lots of episodes where his blood sugar was up and down and he had been in school the day before and then he'd been in athletics and he had passed out and hit his head. And so they admitted him, mostly for observation but also because the physician was very concerned this was the third or fourth episode and so they were very concerned that things were not stabilized the way they needed to be for this, this young child. So I was pretty excited because I thought, oh, for this young child. So I was pretty excited because I thought, oh, this is the perfect patient for my student, because it's not DKA, it's not hyperglycemia, but it's hypoglycemia. So it's the same thinking pattern, right. So my student arrives, I pull her aside, I say you know what? I'm sorry your patient, Mrs X, had to go to the ICU because of hyperglycemia episodes during the night. But it's okay because I have this patient just call him Johnny who was admitted yesterday. He's in third grade and he's a newly identified insulin diabetic and he had an episode. He had several episodes of hypoglycemia. Yesterday passed out and hit his head. They've cleared him, he doesn't have a head injury.

Dr. Kristina Dreifurst:

Mostly, what you're going to do today is reinforce the teaching, particularly around those high activity things at the later in the day, kind of thing. And this really bright student looked at me with absolute horror in her face, absolute horror, and I thought, oh my gosh, does she know this person? I mean, oh my gosh, you know what did I do? And she said I can't take care of that patient. And I said why not? And she said well, I prepped for hyperglycemia, I didn't prep for hypoglycemia.

Dr. Kristina Dreifurst:

And it hit me like how siloed our educational model at that time was and how we were putting students' knowledge into these silos and not helping them see across. That's important because with DML, the one really gem of DML is that near the end, we do this very intentional reflection. So we reflect in action, we reflect on action, and then this piece that I created is called Reflection Beyond Action, and Reflection Beyond Action is the relationship between anticipation and reflection, because you see, as a human being you cannot anticipate something, you cannot reflect on or recall, you just can't. You can't anticipate the unknown because you have nothing to base it on. And so in DML, the last thing we do is the what if? What if, instead of this patient having hyperglycemia and DKA, they had hypoglycemia and they were a new onset insulin dependent diabetic and a kid who had, you know, activities spurts all day long? What would be the same and what would be different? What would be the same and what would be different?

Dr. Kristina Dreifurst:

And helping students to use knowledge breadth and depth across the continuum prepares them in a different way. Because, you see, even in the best of nursing programs, we can only offer them so many clinical experiences. We can only offer them so many clinical experiences between simulation and traditional clinical. You know, it might be 50, maybe, but in the course of their career they're going to have to take care of 50 times 10,000 times another 10,000. And they have to be ready to use the knowledge that we've given them and adapt it across the continuum of health and illness.

Dr. Kristina Dreifurst:

And if we don't teach that, that takes a long time to learn in practice. And I don't know if you've been in practice lately, but sometimes the most senior nurse in a unit or in an area has three years or less experience. And so, again, if we don't actively teach this kind of thinking across, we really don't set our students up for success in practice. So, dml, because of that student, because of that exact incident with that student all those years ago, dml has this piece in it. So it takes Shone's work reflection in action and reflection on action and then adds this extra piece reflection beyond action which I think is the golden nugget of the whole method.

Deb Tauber:

Yeah, thank you so much. What a great example. How did the learner do?

Dr. Kristina Dreifurst:

Yeah, thank you so much. What a great example. How did the learner do so? After she stopped hyperventilating? We talked through what was the same, what was different. I had to go look up a couple things and then she actually did really, really well. She just had to get out of her head that she had prepared for one thing and not another. So, yeah, but I will be forever grateful for her, because what she taught me as a teacher that day has lived with me my entire career.

Deb Tauber:

Yes, we do learn so much from our learners. Now, can you share with our listeners the most important thing you'd like them to know? When you learned it, it changed. I think you just kind of brought that up.

Dr. Kristina Dreifurst:

Yeah, yeah, I think that. I also think that it's very important. Um, part of what the people who study how the brain learns, our cognitive scientists, have really learned is that when you co-create information, it sticks, if you will, better than if you just hear it. I think that in debriefing it's so easy to get into lecture mode to tell, to tell, to tell, to tell. And instead, if you would use questioning to help students they've got it, they've got the information and they just need to put it together. So probe and use questions in a way that helps them come to the answer and if they can't, then use that as an opportunity.

Dr. Kristina Dreifurst:

What do you do in practice if you don't know the answer? If it just isn't there, then what do you do and where do you look and how do you access it quickly? Because that's a skill that people will need in practice and they're not going is a really important skill. Think of what is a question that I can use to have the student come to the answer and toss it out there and see what sticks. If that's too complex, take it back a little, go back, take it, make it a little simpler, take it back a little simpler until you get to where they do know the answer and then walk them forward again Because it's all there but it's crammed in. You know, they have just so much information today and it's all mixed up, and so sometimes they just need help putting it together contextually in this patient situation.

Jerrod Jeffries:

Very well said.

Deb Tauber:

Yes, agree. Now, why don't you tell us a little bit about your new role? Are you looking forward to?

Dr. Kristina Dreifurst:

it Very much. So this is an exciting opportunity for me. It's a big change. So I will be leaving an active teaching role where, mostly for the last 10 years, I have been teaching people who want to be nurse educators. So I feel really comfortable in that space, and prior to that I taught traditional students. But in the last 10 years I focused mostly on graduate students who are becoming nurse educators or nurse faculty. And now what I get to do is really focus on how, on that programmatic piece, on how programs are designed, how programs fit together, how we take pedagogy and curriculum and all of the new things that are coming out, the new information, and how we sift and sort so that we can ensure that we have practice ready nurses both at the pre-licensure and at the graduate level. So, yes, it's going to be. It's going to be a great opportunity. I'm also very excited.

Dr. Kristina Dreifurst:

Right now we're on the precipice of competency-based education and I think that simulation is going to have. It's almost like reinventing simulation. It's almost like the next iteration. It's going to have a really important role and it's going to take a little bit of effort for us, because we have historically used simulation as a safe place to learn in nursing, and we have focused on repetition. You can repeat it, you can repeat it again. We have focused on that. We're going to learn from our mistakes here.

Dr. Kristina Dreifurst:

So now we're going to keep that space and we're going to turn the page, and we're also going to have an opportunity to use simulation as a place for assessment of competency and assessment of developing competency and developed competency, and a place there where we can manipulate the environment and look at so you're competent with this like this? Are you competent if we do it like this? Are you competent if we do it like this? I think that the possibilities are really endless, but it's going to take a different kind of thinking. It's going to take us moving away from simulation is a few opportunities or a place to learn things that are high impact, low frequency.

Dr. Kristina Dreifurst:

To now. We're going to switch it. We're going to now be able to use simulation for high frequency, low impact, repeated, repeated, repeated demonstration of competency, and so I think what it's going to do is be an opportunity for nursing programs to look carefully at infusing a whole lot more SIM into their curriculum for these different reasons, and I think it's going to be exciting. It's going to be. It's going to be the next iteration of sim in in nursing education.

Deb Tauber:

Thank you. Thank you for all that you've done in simulation and and just globally. You've really had an impact on learners and now that's something to be known for.

Dr. Kristina Dreifurst:

Thank you. Thank you, it's been a great journey.

Deb Tauber:

Now. Are there any final words? You'd like our listeners to remember this conversation by?

Dr. Kristina Dreifurst:

I would say that remember that we're always evolving, and if you look at the body of literature around simulation, if you look at that literature from way back when I started in 2005 to where it is now, 20 years later, we've really come a long way, but we have a long way yet to go, and so I would say keep current, continue to get continuing education, pay attention to what's coming out in the research, pay attention to what's coming out from the industry. Everything is changing. Nothing is static in this part of pedagogy, and that's actually a good thing, but it requires that we take the effort to stay current as educators. Our students deserve it. They deserve to have the best that we can give them.

Jerrod Jeffries:

Well said Again yes.

Deb Tauber:

Yeah, very well said. Well, thank you so much for your time and your contributions. We're very grateful and, with that, happy simulating. Thank you.

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