Designing PULSE: A Realtime Annotation Tool to Support Simulation Debriefing

Simulation-based education is a cornerstone of healthcare training, yet instructors often struggle to balance technical simulation management with the need to facilitate deep, reflective debriefing. Furthermore, students who observe simulations rather than participating directly are often underutilized. This study introduces PULSE, a web-based annotation tool designed to help instructors and students mark key events in real-time, which are then used to guide post-simulation debriefing sessions.

The researchers employed a co-design process with nursing educators to develop PULSE, ensuring the tool addressed real-world multitasking challenges. The system provides an instructor interface for flagging positive and negative events and a student interface for recording anonymous, open-ended observations. A field study was conducted with one nursing instructor and six students, comparing three standard debriefing sessions against three sessions supported by PULSE. Effectiveness was measured using the Debriefing Assessment for Simulation in Healthcare (DASH) survey and qualitative follow-up interviews.

The study found that using PULSE led to a statistically significant improvement in overall DASH scores compared to baseline debriefing methods. Qualitative feedback from the instructor highlighted that the tool successfully shifted the debriefing dynamic, making it more student-centered. By allowing observers to contribute their own notes, the tool fostered increased engagement and deeper reflection, as students were able to discuss their specific observations rather than relying solely on instructor-led feedback. The instructor noted that while the tool was highly effective, it required a learning curve to avoid "over-marking" events during the simulation.

This research demonstrates that integrating simple, real-time annotation technology can transform the debriefing process from a passive review into an active, collaborative learning experience. By empowering observing students to contribute to the discussion, educators can mitigate the "observer gap" and ensure that all students—not just those in the simulation—benefit from the reflective process. This approach offers a scalable way to enhance the educational value of simulation without requiring additional staffing.