June 24, 2025 • 32 mins
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
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Episode Transcript
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Welcome to the Sim Cafe, apodcast produced by the team at
Innovative Sim Solutions, editedby Shelley Hauser.
Join our host, deb Tauber, andco-host, jared Jeffries as they
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sit down with subject matterexperts from across the globe to
reimagine clinical educationand the use of simulation.
So pour yourself a cup ofrelaxation, sit back, tune in
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Deb Tauber (01:15):
Welcome to another episode of The SimCafe, and
today Jerrod and I are here withDr Kristina Dreifurst, and Dr
Dreifurst is a distinguishednurse, educator and researcher,
serving as a professor and thedirector of the PhD program at
Marquette University inMilwaukee.
However, in August she's goingto begin working at Vanderbilt
(01:39):
as a senior Associate Dean forAcademics.
So Dr Dreifurst is renowned fordeveloping the Debriefing for
Meaningful Learning DML model, atransformative pedagogical
approach now utilized in over500 nursing programs worldwide.
This method enhances clinicalreasoning and reflective
(02:01):
practice among nursing studentsthrough structured debriefing
sessions.
So we are so grateful to haveyou today.
Thank you so much for willingto be a guest, and why don't you
share a few things withyourself and maybe your journey
into simulation?
Dr. Kristina Dreifurst (02:17):
Thank you.
It is great to be here with allof you today.
My journey really started wayback when I was a nursing
student, which was a long timeago, because I'm one of those
old nurses and I remember veryclearly using an early version
mannequin, Mrs Chase, and infact we spent a lot of time as
(02:40):
students changing Mrs Chase'soutfits and her wigs, and way
back in the 1980s.
So really that's where I gotthe bug and then it was sort of
latent for a while.
But in 2005, I was a newpart-time nurse educator.
I was a clinical educator, Iwas working in the skills lab in
(03:06):
a nursing program at theUniversity of Wisconsin-Madison
and we had received some newmannequins and I was absolutely
fascinated.
These were early, earlyhigh-fidelity mannequins and I
just loved them.
And I had an opportunity in 2005to go to Maryland and spend
some time with the renowned DebSpunt and she really showed me a
(03:32):
lot about the versatility, theway that mannequins could
enhance nursing education.
So after that I had one othermajor sort of lightning
experience.
I had taken my kids in 2006 toDisney in Florida and we went
(03:56):
through the.
It's a small world event and ifyou've ever been to that event
and I am not even sure if thatevent exists anymore, but they
have all kinds of mannequinsdoing different things as you
float by, and what I foundabsolutely fascinating is that
people who were my age were justthrilled with the mannequins,
(04:19):
and people who were younger werenot so sure about them, and
that really got me thinking alot about how we introduce
mannequins and how we make themreal for students, how they can
become actual patients that needto be cared for.
So my journey really startedway back at the beginning and
(04:42):
it's been quite a ride.
Jerrod Jeffries (04:44):
It's a small world after all, yes and well
said, I mean it is.
I think there's right fromwhere you began, back in 2005,.
Of course, 20 years, that'squite the riding scene from very
early conferences, quite theriding scene from very early
(05:09):
conferences, of course, withyour leadership over INASCL as
well, and then into this newworld of alternative realities
that we're experiencing more andmore at every conference we
visit.
So you've certainly beenthrough a lot of different
chapters.
Dr. Kristina Dreifurst (05:20):
Yes, I have.
Deb Tauber (05:21):
Yeah, I love the analogy of of it's a small world
interactions.
It's something that Ioverlooked, but I do recall
being in there feeling the samemagic and not sure what my kids
were thinking.
Dr. Kristina Dreifurst (05:38):
Yeah.
Deb Tauber (05:39):
All right, now you have the DML.
Why don't you tell ourlisteners about DML, how you
created it and its widespreaduniversal use, how that all came
to be?
Dr. Kristina Dreifurst (05:52):
Sure, that's another journey in itself
.
So after my introduction tosimulation and after I'd started
working as a clinicalinstructor, I was still in
practice, but I knew that I wasgoing to probably move my career
fully into education.
And as I was doing that, Idecided that I wanted to go
(06:14):
ahead and get my PhD, because ifthis was going to be what I was
going to do, then I wanted tobe prepared for it and I wanted
to do my doctoral work inpedagogical research.
So I specifically sought outIndiana University at the time
to go and get my PhD and Iwanted to study mannequins and
(06:37):
mannequin simulation and Iwanted to study fidelity because
I really thought that the morefidelity, the better the
learning.
That was what I came to do,that was what I really believed
in.
And I got there.
And in the first week in myprogram I met with my committee
members and I told them I wasall in and excited and I was
(06:59):
going to study fidelity andsimulation.
And I remember sitting thereand it was silent and they were
kind of looking at each otherand one of my committee members
was kind of smirking his mouth,trying not to laugh out loud,
and finally one of them saidokay, and why do you think
fidelity is so important?
And I confidently said becauseI thought that the more the
(07:25):
experience felt real, the betterthe learning students would
have.
And then another one said buthaven't you ever done a case
study and didn't you learn froma case study?
And there was silence again andI was pretty deflated because I
thought OK, so I've been hereone day and already my ideas are
(07:46):
out the door.
Because, yes, I absolutely haveused case studies, saw students
learn from case studies, havelearned myself from case studies
.
So clearly, clearly, learningisn't just tied to fidelity.
So then I had to find somethingelse and so I dove into the
literature, and again, this wasat the time of just the very
(08:07):
beginning, the early NLN Jeffreystudies.
And what the piece that was theleast understood and the least
studied at that point wasdebriefing.
And the model that had beenadopted for those early studies
really came out of the airlineindustry, the military, where
debriefing really came out ofthe airline industry, the
military, where debriefingreally was focused on what went
(08:29):
right, what went wrong and whatwould you do differently.
And so, as I began to delveinto this and I began to watch
people all over the country inthese 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 torealize is that if students knew
(08:52):
what they would do differently,they would have done it.
So asking that really puts themon the spot.
It's a form of feedback andit's a good way to do feedback.
But debriefing had to be morethan and so I again delving into
, as you do in a PhD program,delving into educational theory,
(09:13):
delving into cognitive learning, how the brain learns, how we
take meaningful, meaningfulnuggets and then put them into
action began my journey indeveloping Debriefment for
Meaningful Learning, debriefingfor Meaningful Learning.
(09:34):
And I think the linchpin ofthis method really is that by
using Socratic questioning andthere's a specific piece of DML
where Socratic questioningbecomes the way that the
debriefer and the learnersinteract, that the purpose of
that becomes understanding whatwe call the four square.
(09:54):
Was their right thinking rightaction.
Was their wrong thinking wrongaction.
Was their right thinking wrongaction.
Was their wrong thinking rightaction.
Because you see, as you watchsomebody in sim or in
traditional clinical or inpractice, you're watching what
they're doing and you'rethinking, oh, that all looks
right, that all looks right,that all looks right.
(10:17):
But as a debriefer, in using theSocratic method, it became more
and more and more obvious howoften it was right action, wrong
thinking, right action, wrongthinking.
And in probing that further itbegan it was like I didn't know
(10:37):
what else to do.
I saw somebody do this, itworked last time, and it became
very, very clear that as aneducator, we can't assume that
just because students are doingthe right thing, they're doing
it for the right reason.
And so DML really focuses onunderstanding the relationship
(10:57):
between thinking and actions,and it's less about what's
something methodically donecorrectly, what's the skill?
It's less about the skill.
Skills are important, how youintegrate them into care of a
patient, either in simulation orin practice, or it is important
(11:18):
, but equally important is thethinking, the precipice.
Then, as people including in mywork, but also other schools, as
educators began using DML morefrequently with students
repeatedly, it became clear thatthinking is also a form of
(11:42):
muscle memory.
That by doing this Socraticthinking, by challenging taken
for granted assumptions, byreally probing on the, it looked
like what you did was right.
Let's talk about how you cameto that decision.
How does this fit with this?
How do you put this together?
It became clear that we wereteaching learners to think that
(12:05):
way themselves, that, as theybegan to be comfortable with
this probing and questioning anddialogue and explaining.
This is what I saw, this iswhat it made me think about,
this is what I remembered, thisis what I did, that they began
to do that themselves and theytook that into practice, not
(12:27):
necessarily hearing the voice ofthe debriefer, but
subconsciously hearing.
Does this make sense?
Does it make sense right now?
Is there something else Ishould be thinking about?
And it really changed themetacognition, the clinical
reasoning, the high thinkingthat learners who were using
this debriefing over and overcould demonstrate.
Deb Tauber (12:51):
And I love the fact that it's non-threatening
debriefing for meaningfullearning, just the whole.
When you say it, it sounds likewe want to learn about why
you're thinking this way anddisarms any learner from feeling
threatened.
Dr. Kristina Dreifurst (13:08):
Well, that's our goal.
That's our goal.
I mean, I think there's always.
Students are always nervousbecause they're always worried
that they're going to be judgedfor what they did or for what
they say.
And it takes a lot to learn howto not be defensive when
somebody's asking you aboutsomething that they thought you
(13:30):
did correctly and to becomfortable with that.
But that's also how you learnto be comfortable in practice
asking yourself, boys, ifsomething else I should be
thinking about is that does thismake sense for this patient?
You know my inclination is todo this.
Is there anything else?
And that's, I think that reallyhelps practice.
(13:53):
That really helps us make goodthinkers as clinicians.
Jerrod Jeffries (13:59):
Any activity or pattern you saw on some of
these.
I think you mentioned thatdebriefing or pre-briefing.
Is there anyone just to use anexample of the right action,
wrong thinking?
Dr. Kristina Dreifurst (14:12):
I mean many, there's so many, I think.
What surprised me the most,though?
So debriefing for meaningfullearning really began as a form
of debriefing students, andparticularly it began in nursing
and we focused on thinking likea nurse, and then it morphed
into other disciplines, using itboth for interdisciplinary
(14:34):
debriefing but also for otherhealthcare professions, adopted
it in, then into practice,because now, then again,
simulation went from being aneducational model to being
(14:54):
something that we did inpractice.
We see simulation centers allover in clinical settings, and
what I expected as I started todebrief practicing clinicians, I
expected that there would beless maybe negligible wrong
thinking, right action, but infact it really didn't seem any
(15:19):
different, and that surprised mea lot, that even in practice,
that we have to bring peopleback to what is the thinking
behind this action and is therea match.
And I was really surprised athow often even practicing
(15:40):
seasoned clinicians, as we beganto peel it apart, would
demonstrate right action, wrongthinking.
Deb Tauber (15:49):
Yeah, right action, wrong thinking is a big thing.
To be able to differentiate andrecognize and, like you said,
debrief around.
Dr. Kristina Dreifurst (15:58):
Correct, correct, and I think it helps
us mitigate errors when we canreally peel it apart.
At what point did you come offthe track?
Did the thinking not matcheither the situation or the data
or the information that led tothe decision-making?
(16:20):
Because, again, the action wascorrect and I firmly believe
that you can get away with doingthe right thing for the wrong
reason a few times, but youcannot get away with doing the
right thing for the wrong reasona few times, but you cannot get
away with doing the right thingfor the wrong reason all of the
time.
It's going to catch up to you.
Deb Tauber (16:37):
Absolutely, absolutely.
Now, with all your experience,your vast experience in this, in
actually developing a theoryaround it, do you have a
favorite simulation story thatyou'd like to share with our
listeners today?
Dr. Kristina Dreifurst (17:05):
parallel story.
So way back 20 years ago, whenI 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 inthe hospital and then they would
come the next morning and carefor a patient.
And I had this experience.
It was really in myprofessional role, one of those
life-changing aha moments.
So really good student.
(17:26):
She had prepped to take care ofan elderly patient who had been
admitted in DKA and so, withlots of episodes of
hyperglycemia and as oftenhappened in community hospitals,
during the night she began tofluctuate and they sent her to
the ICU, off of the general careunit, to the ICU.
(17:46):
So the next morning I got thereearly, realized that my student
would need a new patient.
Again, this was a smallcommunity, rural community
hospital where the adultmed-surg patients would be on
the main part of the floor,where the adult med-surg
patients would be on the mainpart of the floor and then the
last six rooms on the end wouldbe for the pediatric patients.
And so, as luck would have it,a young man had been admitted, a
(18:14):
kid had been admitted.
He was a newly diagnosedinsulin-dependent diabetic and
he had been diagnosed probablytwo months prior to his
admission and he'd had a lot ofeducation.
His folks had had a lot ofeducation, but he was still
having lots of episodes wherehis blood sugar was up and down
and he had been in school theday before and then he'd been in
(18:38):
athletics and he had passed outand hit his head.
And so they admitted him,mostly for observation but also
because the physician was veryconcerned this was the third or
fourth episode and so they werevery concerned that things were
not stabilized the way theyneeded to be for this, this
young child.
(18:58):
So I was pretty excited becauseI thought, oh, for this young
child.
So I was pretty excited becauseI thought, oh, this is the
perfect patient for my student,because it's not DKA, it's not
hyperglycemia, but it'shypoglycemia.
So it's the same thinkingpattern, right.
So my student arrives, I pullher aside, I say you know what?
I'm sorry your patient, Mrs X,had to go to the ICU because of
(19:21):
hyperglycemia episodes duringthe night.
But it's okay because I havethis patient just call him
Johnny who was admittedyesterday.
He's in third grade and he's anewly identified insulin
diabetic and he had an episode.
He had several episodes ofhypoglycemia.
(19:41):
Yesterday passed out and hithis head.
They've cleared him, he doesn'thave a head injury.
Mostly, what you're going to dotoday is reinforce the teaching,
particularly around those highactivity things at the later in
the day, kind of thing.
And this really bright studentlooked at me with absolute
(20:02):
horror in her face, absolutehorror, and I thought, oh my
gosh, does she know this person?
I mean, oh my gosh, you knowwhat did I do?
And she said I can't take careof that patient.
And I said why not?
And she said well, I preppedfor hyperglycemia, I didn't prep
for hypoglycemia.
(20:24):
And it hit me like how siloedour educational model at that
time was and how we were puttingstudents' knowledge into these
silos and not helping them seeacross.
That's important because withDML, the one really gem of DML
(20:46):
is that near the end, we do thisvery intentional reflection.
So we reflect in action, wereflect on action, and then this
piece that I created is calledReflection Beyond Action, and
Reflection Beyond Action is therelationship between
anticipation and reflection,because you see, as a human
being you cannot anticipatesomething, you cannot reflect on
(21:09):
or recall, you just can't.
You can't anticipate theunknown because you have nothing
to base it on.
And so in DML, the last thingwe do is the what if?
What if, instead of thispatient having hyperglycemia and
(21:31):
DKA, they had hypoglycemia andthey were a new onset insulin
dependent diabetic and a kid whohad, you know, activities
spurts all day long?
What would be the same and whatwould be different?
What would be the same and whatwould be different?
(21:52):
And helping students to useknowledge breadth and depth
across the continuum preparesthem in a different way.
Because, you see, even in thebest of nursing programs, we can
only offer them so manyclinical experiences.
We can only offer them so manyclinical experiences between
simulation and traditionalclinical.
You know, it might be 50, maybe, but in the course of their
career they're going to have totake care of 50 times 10,000
(22:13):
times another 10,000.
And they have to be ready touse the knowledge that we've
given them and adapt it acrossthe continuum of health and
illness.
And if we don't teach that, thattakes a long time to learn in
practice.
And I don't know if you've beenin practice lately, but
(22:34):
sometimes the most senior nursein a unit or in an area has
three years or less experience.
And so, again, if we don'tactively teach this kind of
thinking across, we really don'tset our students up for success
in practice.
So, dml, because of thatstudent, because of that exact
(22:57):
incident with that student allthose years ago, dml has this
piece in it.
So it takes Shone's workreflection in action and
reflection on action and thenadds this extra piece reflection
beyond action which I think isthe golden nugget of the whole
method.
Deb Tauber (23:17):
Yeah, thank you so much.
What a great example.
How did the learner do?
Dr. Kristina Dreifurst (23:21):
Yeah, thank you so much.
What a great example.
How did the learner do so?
After she stoppedhyperventilating?
We talked through what was thesame, what was different.
I had to go look up a couplethings and then she actually did
really, really well.
She just had to get out of herhead that she had prepared for
one thing and not another.
So, yeah, but I will be forevergrateful for her, because what
(23:43):
she taught me as a teacher thatday has lived with me my entire
career.
Deb Tauber (23:48):
Yes, we do learn so much from our learners.
Now, can you share with ourlisteners the most important
thing you'd like them to know?
When you learned it, it changed.
I think you just kind ofbrought that up.
Dr. Kristina Dreifurst (24:10):
Yeah, yeah, I think that.
I also think that it's veryimportant.
Um, part of what the people whostudy how the brain learns, our
cognitive scientists, havereally 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'sso easy to get into lecture
mode to tell, to tell, to tell,to tell.
(24:32):
And instead, if you would usequestioning to help students
they've got it, they've got theinformation and they just need
to put it together.
So probe and use questions in away that helps them come to the
answer and if they can't, thenuse that as an opportunity.
(24:52):
What do you do in practice ifyou don't know the answer?
If it just isn't there, thenwhat do you do and where do you
look and how do you access itquickly?
Because that's a skill thatpeople will need in practice and
(25:24):
they're not going is a reallyimportant skill.
Think of what is a questionthat I can use to have the
(25:45):
student come to the answer andtoss it out there and see what
sticks.
If that's too complex, take itback a little, go back, take it,
make it a little simpler, takeit back a little simpler until
you get to where they do knowthe answer and then walk them
forward again Because it's allthere but it's crammed in.
(26:05):
You know, they have just somuch information today and it's
all mixed up, and so sometimesthey just need help putting it
together contextually in thispatient situation.
Jerrod Jeffries (26:20):
Very well said.
Deb Tauber (26:26):
Yes, agree.
Now, why don't you tell us alittle bit about your new role?
Are you looking forward to?
Dr. Kristina Dreifurst (26:29):
it Very much.
So this is an excitingopportunity for me.
It's a big change.
So I will be leaving an activeteaching role where, mostly for
the last 10 years, I have beenteaching people who want to be
nurse educators.
So I feel really comfortable inthat space, and prior to that I
(26:51):
taught traditional students.
But in the last 10 years Ifocused mostly on graduate
students who are becoming nurseeducators or nurse faculty.
And now what I get to do isreally focus on how, on that
programmatic piece, on howprograms are designed, how
programs fit together, how wetake pedagogy and curriculum and
(27:16):
all of the new things that arecoming out, the new information,
and how we sift and sort sothat we can ensure that we have
practice ready nurses both atthe pre-licensure and at the
graduate level.
So, yes, it's going to be.
It's going to be a greatopportunity.
I'm also very excited.
Right now we're on the precipiceof competency-based education
(27:40):
and I think that simulation isgoing to have.
It's almost like reinventingsimulation.
It's almost like the nextiteration.
It's going to have a reallyimportant role and it's going to
take a little bit of effort forus, because we have
historically used simulation asa safe place to learn in nursing
(28:03):
, and we have focused onrepetition.
You can repeat it, you canrepeat it again.
We have focused on that.
We're going to learn from ourmistakes here.
So now we're going to keep thatspace and we're going to turn
the page, and we're also goingto have an opportunity to use
(28:24):
simulation as a place forassessment of competency and
assessment of developingcompetency and developed
competency, and a place therewhere we can manipulate the
environment and look at soyou're competent with this like
this?
Are you competent if we do itlike this?
Are you competent if we do itlike this?
(28:46):
I think that the possibilitiesare really endless, but it's
going to take a different kindof thinking.
It's going to take us movingaway from simulation is a few
opportunities or a place tolearn things that are high
(29:08):
impact, low frequency.
To now.
We're going to switch it.
We're going to now be able touse simulation for high
frequency, low impact, repeated,repeated, repeated
demonstration of competency, andso I think what it's going to
do is be an opportunity fornursing programs to look
(29:30):
carefully at infusing a wholelot more SIM into their
curriculum for these differentreasons, and I think it's going
to be exciting.
It's going to be.
It's going to be the nextiteration of sim in in nursing
education.
Deb Tauber (29:50):
Thank you.
Thank you for all that you'vedone in simulation and and just
globally.
You've really had an impact onlearners and now that's
something to be known for.
Dr. Kristina Dreifurst (30:05):
Thank you.
Thank you, it's been a greatjourney.
Deb Tauber (30:09):
Now.
Are there any final words?
You'd like our listeners toremember this conversation by?
Dr. Kristina Dreifurst (30:17):
I would say that remember that we're
always evolving, and if you lookat the body of literature
around simulation, if you lookat that literature from way back
when I started in 2005 to whereit is now, 20 years later,
we've really come a long way,but we have a long way yet to go
(30:42):
, and so I would say keepcurrent, continue to get
continuing education, payattention to what's coming out
in the research, pay attentionto what's coming out from the
industry.
Everything is changing.
Nothing is static in this partof pedagogy, and that's actually
(31:04):
a good thing, but it requiresthat we take the effort to stay
current as educators.
Our students deserve it.
They deserve to have the bestthat we can give them.
Jerrod Jeffries (31:18):
Well said Again yes.
Deb Tauber (31:20):
Yeah, very well said .
Well, thank you so much foryour time and your contributions
.
We're very grateful and, withthat, happy simulating.
Thank you.
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(00:49):
sit down with subject matterexperts from across the globe to
reimagine clinical educationand the use of simulation.
So pour yourself a cup ofrelaxation, sit back, tune in
and learn something new from theSimCafe.
Deb Tauber (01:15):
Welcome to another episode of The SimCafe, and
today Jerrod and I are here withDr Kristina Dreifurst, and Dr
Dreifurst is a distinguishednurse, educator and researcher,
serving as a professor and thedirector of the PhD program at
Marquette University inMilwaukee.
However, in August she's goingto begin working at Vanderbilt
(01:39):
as a senior Associate Dean forAcademics.
So Dr Dreifurst is renowned fordeveloping the Debriefing for
Meaningful Learning DML model, atransformative pedagogical
approach now utilized in over500 nursing programs worldwide.
This method enhances clinicalreasoning and reflective
(02:01):
practice among nursing studentsthrough structured debriefing
sessions.
So we are so grateful to haveyou today.
Thank you so much for willingto be a guest, and why don't you
share a few things withyourself and maybe your journey
into simulation?
Dr. Kristina Dreifurst (02:17):
Thank you.
It is great to be here with allof you today.
My journey really started wayback when I was a nursing
student, which was a long timeago, because I'm one of those
old nurses and I remember veryclearly using an early version
mannequin, Mrs Chase, and infact we spent a lot of time as
(02:40):
students changing Mrs Chase'soutfits and her wigs, and way
back in the 1980s.
So really that's where I gotthe bug and then it was sort of
latent for a while.
But in 2005, I was a newpart-time nurse educator.
I was a clinical educator, Iwas working in the skills lab in
(03:06):
a nursing program at theUniversity of Wisconsin-Madison
and we had received some newmannequins and I was absolutely
fascinated.
These were early, earlyhigh-fidelity mannequins and I
just loved them.
And I had an opportunity in 2005to go to Maryland and spend
some time with the renowned DebSpunt and she really showed me a
(03:32):
lot about the versatility, theway that mannequins could
enhance nursing education.
So after that I had one othermajor sort of lightning
experience.
I had taken my kids in 2006 toDisney in Florida and we went
(03:56):
through the.
It's a small world event and ifyou've ever been to that event
and I am not even sure if thatevent exists anymore, but they
have all kinds of mannequinsdoing different things as you
float by, and what I foundabsolutely fascinating is that
people who were my age were justthrilled with the mannequins,
(04:19):
and people who were younger werenot so sure about them, and
that really got me thinking alot about how we introduce
mannequins and how we make themreal for students, how they can
become actual patients that needto be cared for.
So my journey really startedway back at the beginning and
(04:42):
it's been quite a ride.
Jerrod Jeffries (04:44):
It's a small world after all, yes and well
said, I mean it is.
I think there's right fromwhere you began, back in 2005,.
Of course, 20 years, that'squite the riding scene from very
early conferences, quite theriding scene from very early
(05:09):
conferences, of course, withyour leadership over INASCL as
well, and then into this newworld of alternative realities
that we're experiencing more andmore at every conference we
visit.
So you've certainly beenthrough a lot of different
chapters.
Dr. Kristina Dreifurst (05:20):
Yes, I have.
Deb Tauber (05:21):
Yeah, I love the analogy of of it's a small world
interactions.
It's something that Ioverlooked, but I do recall
being in there feeling the samemagic and not sure what my kids
were thinking.
Dr. Kristina Dreifurst (05:38):
Yeah.
Deb Tauber (05:39):
All right, now you have the DML.
Why don't you tell ourlisteners about DML, how you
created it and its widespreaduniversal use, how that all came
to be?
Dr. Kristina Dreifurst (05:52):
Sure, that's another journey in itself
.
So after my introduction tosimulation and after I'd started
working as a clinicalinstructor, I was still in
practice, but I knew that I wasgoing to probably move my career
fully into education.
And as I was doing that, Idecided that I wanted to go
(06:14):
ahead and get my PhD, because ifthis was going to be what I was
going to do, then I wanted tobe prepared for it and I wanted
to do my doctoral work inpedagogical research.
So I specifically sought outIndiana University at the time
to go and get my PhD and Iwanted to study mannequins and
(06:37):
mannequin simulation and Iwanted to study fidelity because
I really thought that the morefidelity, the better the
learning.
That was what I came to do,that was what I really believed
in.
And I got there.
And in the first week in myprogram I met with my committee
members and I told them I wasall in and excited and I was
(06:59):
going to study fidelity andsimulation.
And I remember sitting thereand it was silent and they were
kind of looking at each otherand one of my committee members
was kind of smirking his mouth,trying not to laugh out loud,
and finally one of them saidokay, and why do you think
fidelity is so important?
And I confidently said becauseI thought that the more the
(07:25):
experience felt real, the betterthe learning students would
have.
And then another one said buthaven't you ever done a case
study and didn't you learn froma case study?
And there was silence again andI was pretty deflated because I
thought OK, so I've been hereone day and already my ideas are
(07:46):
out the door.
Because, yes, I absolutely haveused case studies, saw students
learn from case studies, havelearned myself from case studies
.
So clearly, clearly, learningisn't just tied to fidelity.
So then I had to find somethingelse and so I dove into the
literature, and again, this wasat the time of just the very
(08:07):
beginning, the early NLN Jeffreystudies.
And what the piece that was theleast understood and the least
studied at that point wasdebriefing.
And the model that had beenadopted for those early studies
really came out of the airlineindustry, the military, where
debriefing really came out ofthe airline industry, the
military, where debriefingreally was focused on what went
(08:29):
right, what went wrong and whatwould you do differently.
And so, as I began to delveinto this and I began to watch
people all over the country inthese 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 torealize is that if students knew
(08:52):
what they would do differently,they would have done it.
So asking that really puts themon the spot.
It's a form of feedback andit's a good way to do feedback.
But debriefing had to be morethan and so I again delving into
, as you do in a PhD program,delving into educational theory,
(09:13):
delving into cognitive learning, how the brain learns, how we
take meaningful, meaningfulnuggets and then put them into
action began my journey indeveloping Debriefment for
Meaningful Learning, debriefingfor Meaningful Learning.
(09:34):
And I think the linchpin ofthis method really is that by
using Socratic questioning andthere's a specific piece of DML
where Socratic questioningbecomes the way that the
debriefer and the learnersinteract, that the purpose of
that becomes understanding whatwe call the four square.
(09:54):
Was their right thinking rightaction.
Was their wrong thinking wrongaction.
Was their right thinking wrongaction.
Was their wrong thinking rightaction.
Because you see, as you watchsomebody in sim or in
traditional clinical or inpractice, you're watching what
they're doing and you'rethinking, oh, that all looks
right, that all looks right,that all looks right.
(10:17):
But as a debriefer, in using theSocratic method, it became more
and more and more obvious howoften it was right action, wrong
thinking, right action, wrongthinking.
And in probing that further itbegan it was like I didn't know
(10:37):
what else to do.
I saw somebody do this, itworked last time, and it became
very, very clear that as aneducator, we can't assume that
just because students are doingthe right thing, they're doing
it for the right reason.
And so DML really focuses onunderstanding the relationship
(10:57):
between thinking and actions,and it's less about what's
something methodically donecorrectly, what's the skill?
It's less about the skill.
Skills are important, how youintegrate them into care of a
patient, either in simulation orin practice, or it is important
(11:18):
, but equally important is thethinking, the precipice.
Then, as people including in mywork, but also other schools, as
educators began using DML morefrequently with students
repeatedly, it became clear thatthinking is also a form of
(11:42):
muscle memory.
That by doing this Socraticthinking, by challenging taken
for granted assumptions, byreally probing on the, it looked
like what you did was right.
Let's talk about how you cameto that decision.
How does this fit with this?
How do you put this together?
It became clear that we wereteaching learners to think that
(12:05):
way themselves, that, as theybegan to be comfortable with
this probing and questioning anddialogue and explaining.
This is what I saw, this iswhat it made me think about,
this is what I remembered, thisis what I did, that they began
to do that themselves and theytook that into practice, not
(12:27):
necessarily hearing the voice ofthe debriefer, but
subconsciously hearing.
Does this make sense?
Does it make sense right now?
Is there something else Ishould be thinking about?
And it really changed themetacognition, the clinical
reasoning, the high thinkingthat learners who were using
this debriefing over and overcould demonstrate.
Deb Tauber (12:51):
And I love the fact that it's non-threatening
debriefing for meaningfullearning, just the whole.
When you say it, it sounds likewe want to learn about why
you're thinking this way anddisarms any learner from feeling
threatened.
Dr. Kristina Dreifurst (13:08):
Well, that's our goal.
That's our goal.
I mean, I think there's always.
Students are always nervousbecause they're always worried
that they're going to be judgedfor what they did or for what
they say.
And it takes a lot to learn howto not be defensive when
somebody's asking you aboutsomething that they thought you
(13:30):
did correctly and to becomfortable with that.
But that's also how you learnto be comfortable in practice
asking yourself, boys, ifsomething else I should be
thinking about is that does thismake sense for this patient?
You know my inclination is todo this.
Is there anything else?
And that's, I think that reallyhelps practice.
(13:53):
That really helps us make goodthinkers as clinicians.
Jerrod Jeffries (13:59):
Any activity or pattern you saw on some of
these.
I think you mentioned thatdebriefing or pre-briefing.
Is there anyone just to use anexample of the right action,
wrong thinking?
Dr. Kristina Dreifurst (14:12):
I mean many, there's so many, I think.
What surprised me the most,though?
So debriefing for meaningfullearning really began as a form
of debriefing students, andparticularly it began in nursing
and we focused on thinking likea nurse, and then it morphed
into other disciplines, using itboth for interdisciplinary
(14:34):
debriefing but also for otherhealthcare professions, adopted
it in, then into practice,because now, then again,
simulation went from being aneducational model to being
(14:54):
something that we did inpractice.
We see simulation centers allover in clinical settings, and
what I expected as I started todebrief practicing clinicians, I
expected that there would beless maybe negligible wrong
thinking, right action, but infact it really didn't seem any
(15:19):
different, and that surprised mea lot, that even in practice,
that we have to bring peopleback to what is the thinking
behind this action and is therea match.
And I was really surprised athow often even practicing
(15:40):
seasoned clinicians, as we beganto peel it apart, would
demonstrate right action, wrongthinking.
Deb Tauber (15:49):
Yeah, right action, wrong thinking is a big thing.
To be able to differentiate andrecognize and, like you said,
debrief around.
Dr. Kristina Dreifurst (15:58):
Correct, correct, and I think it helps
us mitigate errors when we canreally peel it apart.
At what point did you come offthe track?
Did the thinking not matcheither the situation or the data
or the information that led tothe decision-making?
(16:20):
Because, again, the action wascorrect and I firmly believe
that you can get away with doingthe right thing for the wrong
reason a few times, but youcannot get away with doing the
right thing for the wrong reasona few times, but you cannot get
away with doing the right thingfor the wrong reason all of the
time.
It's going to catch up to you.
Deb Tauber (16:37):
Absolutely, absolutely.
Now, with all your experience,your vast experience in this, in
actually developing a theoryaround it, do you have a
favorite simulation story thatyou'd like to share with our
listeners today?
Dr. Kristina Dreifurst (17:05):
parallel story.
So way back 20 years ago, whenI 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 inthe hospital and then they would
come the next morning and carefor a patient.
And I had this experience.
It was really in myprofessional role, one of those
life-changing aha moments.
So really good student.
(17:26):
She had prepped to take care ofan elderly patient who had been
admitted in DKA and so, withlots of episodes of
hyperglycemia and as oftenhappened in community hospitals,
during the night she began tofluctuate and they sent her to
the ICU, off of the general careunit, to the ICU.
(17:46):
So the next morning I got thereearly, realized that my student
would need a new patient.
Again, this was a smallcommunity, rural community
hospital where the adultmed-surg patients would be on
the main part of the floor,where the adult med-surg
patients would be on the mainpart of the floor and then the
last six rooms on the end wouldbe for the pediatric patients.
And so, as luck would have it,a young man had been admitted, a
(18:14):
kid had been admitted.
He was a newly diagnosedinsulin-dependent diabetic and
he had been diagnosed probablytwo months prior to his
admission and he'd had a lot ofeducation.
His folks had had a lot ofeducation, but he was still
having lots of episodes wherehis blood sugar was up and down
and he had been in school theday before and then he'd been in
(18:38):
athletics and he had passed outand hit his head.
And so they admitted him,mostly for observation but also
because the physician was veryconcerned this was the third or
fourth episode and so they werevery concerned that things were
not stabilized the way theyneeded to be for this, this
young child.
(18:58):
So I was pretty excited becauseI thought, oh, for this young
child.
So I was pretty excited becauseI thought, oh, this is the
perfect patient for my student,because it's not DKA, it's not
hyperglycemia, but it'shypoglycemia.
So it's the same thinkingpattern, right.
So my student arrives, I pullher aside, I say you know what?
I'm sorry your patient, Mrs X,had to go to the ICU because of
(19:21):
hyperglycemia episodes duringthe night.
But it's okay because I havethis patient just call him
Johnny who was admittedyesterday.
He's in third grade and he's anewly identified insulin
diabetic and he had an episode.
He had several episodes ofhypoglycemia.
(19:41):
Yesterday passed out and hithis head.
They've cleared him, he doesn'thave a head injury.
Mostly, what you're going to dotoday is reinforce the teaching,
particularly around those highactivity things at the later in
the day, kind of thing.
And this really bright studentlooked at me with absolute
(20:02):
horror in her face, absolutehorror, and I thought, oh my
gosh, does she know this person?
I mean, oh my gosh, you knowwhat did I do?
And she said I can't take careof that patient.
And I said why not?
And she said well, I preppedfor hyperglycemia, I didn't prep
for hypoglycemia.
(20:24):
And it hit me like how siloedour educational model at that
time was and how we were puttingstudents' knowledge into these
silos and not helping them seeacross.
That's important because withDML, the one really gem of DML
(20:46):
is that near the end, we do thisvery intentional reflection.
So we reflect in action, wereflect on action, and then this
piece that I created is calledReflection Beyond Action, and
Reflection Beyond Action is therelationship between
anticipation and reflection,because you see, as a human
being you cannot anticipatesomething, you cannot reflect on
(21:09):
or recall, you just can't.
You can't anticipate theunknown because you have nothing
to base it on.
And so in DML, the last thingwe do is the what if?
What if, instead of thispatient having hyperglycemia and
(21:31):
DKA, they had hypoglycemia andthey were a new onset insulin
dependent diabetic and a kid whohad, you know, activities
spurts all day long?
What would be the same and whatwould be different?
What would be the same and whatwould be different?
(21:52):
And helping students to useknowledge breadth and depth
across the continuum preparesthem in a different way.
Because, you see, even in thebest of nursing programs, we can
only offer them so manyclinical experiences.
We can only offer them so manyclinical experiences between
simulation and traditionalclinical.
You know, it might be 50, maybe, but in the course of their
career they're going to have totake care of 50 times 10,000
(22:13):
times another 10,000.
And they have to be ready touse the knowledge that we've
given them and adapt it acrossthe continuum of health and
illness.
And if we don't teach that, thattakes a long time to learn in
practice.
And I don't know if you've beenin practice lately, but
(22:34):
sometimes the most senior nursein a unit or in an area has
three years or less experience.
And so, again, if we don'tactively teach this kind of
thinking across, we really don'tset our students up for success
in practice.
So, dml, because of thatstudent, because of that exact
(22:57):
incident with that student allthose years ago, dml has this
piece in it.
So it takes Shone's workreflection in action and
reflection on action and thenadds this extra piece reflection
beyond action which I think isthe golden nugget of the whole
method.
Deb Tauber (23:17):
Yeah, thank you so much.
What a great example.
How did the learner do?
Dr. Kristina Dreifurst (23:21):
Yeah, thank you so much.
What a great example.
How did the learner do so?
After she stoppedhyperventilating?
We talked through what was thesame, what was different.
I had to go look up a couplethings and then she actually did
really, really well.
She just had to get out of herhead that she had prepared for
one thing and not another.
So, yeah, but I will be forevergrateful for her, because what
(23:43):
she taught me as a teacher thatday has lived with me my entire
career.
Deb Tauber (23:48):
Yes, we do learn so much from our learners.
Now, can you share with ourlisteners the most important
thing you'd like them to know?
When you learned it, it changed.
I think you just kind ofbrought that up.
Dr. Kristina Dreifurst (24:10):
Yeah, yeah, I think that.
I also think that it's veryimportant.
Um, part of what the people whostudy how the brain learns, our
cognitive scientists, havereally 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'sso easy to get into lecture
mode to tell, to tell, to tell,to tell.
(24:32):
And instead, if you would usequestioning to help students
they've got it, they've got theinformation and they just need
to put it together.
So probe and use questions in away that helps them come to the
answer and if they can't, thenuse that as an opportunity.
(24:52):
What do you do in practice ifyou don't know the answer?
If it just isn't there, thenwhat do you do and where do you
look and how do you access itquickly?
Because that's a skill thatpeople will need in practice and
(25:24):
they're not going is a reallyimportant skill.
Think of what is a questionthat I can use to have the
(25:45):
student come to the answer andtoss it out there and see what
sticks.
If that's too complex, take itback a little, go back, take it,
make it a little simpler, takeit back a little simpler until
you get to where they do knowthe answer and then walk them
forward again Because it's allthere but it's crammed in.
(26:05):
You know, they have just somuch information today and it's
all mixed up, and so sometimesthey just need help putting it
together contextually in thispatient situation.
Jerrod Jeffries (26:20):
Very well said.
Deb Tauber (26:26):
Yes, agree.
Now, why don't you tell us alittle bit about your new role?
Are you looking forward to?
Dr. Kristina Dreifurst (26:29):
it Very much.
So this is an excitingopportunity for me.
It's a big change.
So I will be leaving an activeteaching role where, mostly for
the last 10 years, I have beenteaching people who want to be
nurse educators.
So I feel really comfortable inthat space, and prior to that I
(26:51):
taught traditional students.
But in the last 10 years Ifocused mostly on graduate
students who are becoming nurseeducators or nurse faculty.
And now what I get to do isreally focus on how, on that
programmatic piece, on howprograms are designed, how
programs fit together, how wetake pedagogy and curriculum and
(27:16):
all of the new things that arecoming out, the new information,
and how we sift and sort sothat we can ensure that we have
practice ready nurses both atthe pre-licensure and at the
graduate level.
So, yes, it's going to be.
It's going to be a greatopportunity.
I'm also very excited.
Right now we're on the precipiceof competency-based education
(27:40):
and I think that simulation isgoing to have.
It's almost like reinventingsimulation.
It's almost like the nextiteration.
It's going to have a reallyimportant role and it's going to
take a little bit of effort forus, because we have
historically used simulation asa safe place to learn in nursing
(28:03):
, and we have focused onrepetition.
You can repeat it, you canrepeat it again.
We have focused on that.
We're going to learn from ourmistakes here.
So now we're going to keep thatspace and we're going to turn
the page, and we're also goingto have an opportunity to use
(28:24):
simulation as a place forassessment of competency and
assessment of developingcompetency and developed
competency, and a place therewhere we can manipulate the
environment and look at soyou're competent with this like
this?
Are you competent if we do itlike this?
Are you competent if we do itlike this?
(28:46):
I think that the possibilitiesare really endless, but it's
going to take a different kindof thinking.
It's going to take us movingaway from simulation is a few
opportunities or a place tolearn things that are high
(29:08):
impact, low frequency.
To now.
We're going to switch it.
We're going to now be able touse simulation for high
frequency, low impact, repeated,repeated, repeated
demonstration of competency, andso I think what it's going to
do is be an opportunity fornursing programs to look
(29:30):
carefully at infusing a wholelot more SIM into their
curriculum for these differentreasons, and I think it's going
to be exciting.
It's going to be.
It's going to be the nextiteration of sim in in nursing
education.
Deb Tauber (29:50):
Thank you.
Thank you for all that you'vedone in simulation and and just
globally.
You've really had an impact onlearners and now that's
something to be known for.
Dr. Kristina Dreifurst (30:05):
Thank you.
Thank you, it's been a greatjourney.
Deb Tauber (30:09):
Now.
Are there any final words?
You'd like our listeners toremember this conversation by?
Dr. Kristina Dreifurst (30:17):
I would say that remember that we're
always evolving, and if you lookat the body of literature
around simulation, if you lookat that literature from way back
when I started in 2005 to whereit is now, 20 years later,
we've really come a long way,but we have a long way yet to go
(30:42):
, and so I would say keepcurrent, continue to get
continuing education, payattention to what's coming out
in the research, pay attentionto what's coming out from the
industry.
Everything is changing.
Nothing is static in this partof pedagogy, and that's actually
(31:04):
a good thing, but it requiresthat we take the effort to stay
current as educators.
Our students deserve it.
They deserve to have the bestthat we can give them.
Jerrod Jeffries (31:18):
Well said Again yes.
Deb Tauber (31:20):
Yeah, very well said .
Well, thank you so much foryour time and your contributions
.
We're very grateful and, withthat, happy simulating.
Thank you.
Diclaimer/ Beaker Health (31:32):
Thanks to Beaker Health for sponsoring
this week's podcast.
Beaker Health, wheredissemination and measuring
impact comes easy.
Thanks for joining us here atThe Sim Cafe.
We hope you enjoyed.
(31:52):
Visit us at www.
InnovativeSimSolutions.
com and be sure to hit that likeand subscribe button so you
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