Objectives Discuss overall goals of debriefing Identify characteristics of effective facilitators for reflective dialogue. Describe debriefing strategies. Recognize common facilitator pitfalls.
Offer a safe, educational experience Constructively correct behavior, attitudes, actions that hamper individual & team performance Encourage metacognition (self- learning/assessment) Promote communication & debriefing among team members Sponsor a culture change to improve the attitude toward ‘errors’ Facilitate dialogue Mort, T.C. & Donahue, S.P (2004). “Simulators in Critical Care and Beyond” Goals of Debriefing
Facilitating Dialogue Why is this important? »Reveals diversity of opinion “that lies just below the surface of almost any complex issue.” (Brookfield & Preskill, 1999, p. 3) »Health care culture is complex »Deeply embedded issues drive the culture
We can see the behavior, but is it the tip of the iceberg?
By listening, we can begin to understand one’s beliefs, but does that tell us everything?
Through the debriefing process, we hope to discover beliefs, values and thought patterns…
Should not be taken lightly “Debriefing is very constructive but can also be psychologically traumatic for certain individuals or when used improperly. The debriefing process should be respected, and quality debriefing must always be a priority.” Seropian, Brown, Gavilanes & Driggers, 2004, p. 168
How Dialogue Can Transform Uncovering assumptions »Learners question and explore widely accepted ideas and beliefs »Learners learn to be open and rethink long held assumptions »Learners increase awareness of and tolerance for ambiguity or complexity »Learners begin to question their assumptions »Learners begin to understand how their assumptions and choices… »Perpetuate an unhealthy culture, including silence »Contribute to growth and healthy culture
The best facilitators provide a disciplined and structured debriefing environment with a minimal speaking role for themselves. Turner & Kurtz, (2008)
Six Key Elements of Effective Debriefers 1.Establishes an engaging learning environment 2.Maintains an engaging learning environment 3.Structures debriefing in an organized way 4.Provokes engaging discussions 5.Identifies and explores performance gaps 6.Helps trainees achieve and maintain good future performance Debriefing Assessment For Simulation in Healthcare-Center for Medical Simulation
1. Establishes an engaging learning environment Clarifies course objectives, environment, roles and expectations »“Today we will run three simulations focusing on teamwork and communication…” Establishes a fiction contract with participants »“Your learning will be significantly enhanced if you can suspend disbelief…” Attends to logistical details »“You will find the IV fluids in this closet…” Conveys a commitment to respecting learners and understanding their perspectives »“We know that you are highly intelligent, skilled and committed to excellence. You are here to enhance those skills through simulation experiences.”
2. Maintains an engaging learning environment Clarifies debriefing objectives, roles and expectations »“We will discuss how the team communicated and worked together…” Helps participants engage in a limited realism contract »“We want you to perform in the simulation as if you were in the ICU caring for a patient.”
3. Structures the debriefing in an organized fashion Encourages learners to express their reactions »“How do you think that went?” Guides an analysis of the learners performance »“Walk us through what you were thinking when you chose….” Collaborates with learners to summarize learning from the session »“How was your performance affected by the distractions that you encountered?“
4. Provokes engaging discussions Uses concrete examples and outcomes as the basis for inquiry and discussion »“Can someone share a story from practice that is similar?” Reveals own reasoning and judgment »“I have used critical language in the following situations with good success….” Facilitates discussion using verbal and non-verbal techniques Recognizes and manages the upset participant »“We have all made mistakes and this is the best place to make them and then we can all learn and go forward from here.”
5. Identifies and discusses performance gaps Provides feedback on performance »“Being the team leader is difficult! Can you reflect on how you might have gained control of the chaos sooner?” Explores the source of the performance gap »“Tell us what you were thinking through when you chose to give that medication.”
6. Helps learners sustain performance Helps the learners close the performance gap through discussion and teaching Demonstrates a firm grasp of the subject matter Meets important objectives of the session
Reactions -Understanding-Summary Feelings often spill out on the way to the debriefing room Spontaneous sharing occurs Clears the air & set the stage for discussion Provide a brief summary of the clinical scenario with an expression of gratitude for the student’s participation in an upbeat manner Adapted from lecture content from Center for Medical Simulation, Cambridge, MA 3
Reactions-Understanding-Summary Goal = to understand what happened & explore deeper meaning: »Facilitate student self-reflection »What results were produced? »What actions led to those results? »What frames or situational factors “set up” these actions and results?
Reactions-Understanding-Summary Review what was learned & ensure that the single scenario is put into a larger context May use +/▲
Plus/Delta Plus indicates things that went well Delta indicates things that need to be changed & how to change them +▲
Advocacy/Inquiry Put your observations/ thoughts into an ADVOCACY statement: » “It is hard to be the team leader…” » “That was a tough situation….” »“I noticed you…” 2 Argyris, C. Putman, R., & McLain Smith, D. 2000
» “Can you walk me through your thinking when you made that decision?” »“Help me understand your reasoning for that decision.” » “Can you tell me what you were thinking when you entered the OR?” Then, follow up with probing INQUIRY: Advocacy/Inquiry
ADVOCACY + INQUIRY “It is hard to challenge a colleague even when they are wrong. What do you think stopped you from correcting them?” “It seemed pretty chaotic when the patient’s condition started to decline. John, did you know who was in charge?” “Barb, I noticed that you did not speak up when the resident ordered the wrong dose, can you help me understand what might have prevented you from speaking up?”
Putting it all Together Scenario Occurs Debrief Reaction-Understanding Advocacy/Inquiry Summary Plus-Delta Application in Practice
Pitfalls Don’t lecture Don’t be vague Don’t play favorites Don’t fear silence Don’t misinterpret silence Don’t answer your own questions
Dirty Questions a2 “Did it occur to you to call for help?” “Do you think you should have done that?” “Why wouldn’t you ask for help?” (avoid them!)
Adapted from Mort, T.C. & Donahue, S.P (2004). “Simulators in Critical Care and Beyond”. More Pitfalls… Inadequate “up-front” review of purpose, objectives, simulator or expectations Lingering discussion of limitations of simulation Being autocratic, picky, or too critical of student’s performance (or allowing others to do so) Monopolizing the “discussion” Trying to highlight too many “key” points Underestimating emotional impact on students Lengthy debriefings
When learners talk to much: Note reactions from other learners in the class: »They try to cut them off »People raise their hand »Eye rolling »Resigned looks »Glowering »Frowning »Feigning sleep »Refusing to make eye contact with speaker »Side conversations
Why Learners Talk Too Much Personality traits Insecurity Nervousness Desire to control Readiness to jump in and dominate discussions is expected and legitimated by the society
How To Manage Role model Ground rules Acknowledge & move on Call on others Call for periods of reflective silence
When Learners Talk Too Little Shifting of bodies and aversion of eyes > 20 seconds Too little time for reflection Fear of looking stupid Introversion Shyness Feeling unprepared Fearing a trap Feeling unwelcome Did not perform well Bad experience Authority Maintaining one’s cool Reliance on facilitator Lack of reward
They really will say something! Be patient or may develop learner dependence on instructor Some learners are processors If you do not get a response, ask “Is there something about my question that… »…was unclear »…was difficult to address »…seemed to easy or obvious Encourage learners to talk with one another
Techniques for Silence Benefits of using silence: Studies show that waiting 3-10 seconds after asking a question greatly improves the number and quality of responses (Dillon, 1994, p. 90) What to do during silence? Look relaxed, sit back, smile MSR, Israel Center for Medical Simulation
When Learners are Resistant or Upset Prevention is the goal »Set the stage »Establish trust »Ensure confidentiality »Convey an interest (words, tone, body language) »Performance expectations »Identify limitation of simulation and simulators »Focus on learning through practice Institute for Medical Simulation Comprehensive Workshop
Examples Phrases »This is not real… »I don’t like being tricked… »You set me up… »I would never do that in practice… »This is humiliating… Manifestations »Body language »Closed »Eye rolling »Slouched »Pushes away from table »Argumentative »Monopolizes the conversation »Crying »Triggered old or new »Insecure »Anxiety Institute for Medical Simulation Comprehensive Workshop
When Learners are Resistant or Upset Avoid arguing »Be aware of how your emotions get in the way Acceptance, diagnosis and response »Acknowledging is not the same as agreeing »Try to mirror feelings rather than evaluating them »Don’t tell them it is okay, when it may not be »Take the focus away from individual in “hot seat” »Share your perspective »“I’ve seen this a dozen times and this happens nearly every time” »“I’ve made the same mistake” »“We all make mistakes and this is a good place to learn from them” MSR, Israel Center for Medical Simulation
When Learners are Resistant or Upset Normalize »Redirect to productive discussion – real world, clinical focus »Clinical discussions are in the comfort zone »Have you seen this ever happen in practice? »Give a personal example Thank learner for taking a risk Praise specifically and concretely “your comment has made clear for me…” “I tried to set up the scenario perfectly, but you helped me see I omitted some key elements. Thanks for paying attention.” “Your feedback will help with the next session and bring us to a higher level.” Institute for Medical Simulation Comprehensive Workshop
When Learners are Resistant or Upset Change the pace »Time-out might be appropriate Focus discussion on less highly- charged content Consider when you need to follow-up »One-on-one conversation after class »Follow-up phone call
Role of Associate Debriefer Determine up front who will be primary debriefer Establish cues Stay sensitive to the points the primary debriefer is pursuing »Add another dimension to the point »Provide example to elaborate primary’s points May have to intervene »Learners are frustrated & confused »Primary debriefer loses situational awareness »Dysfunctional behavior is observed
Resources/References Argyris, C., Putnam, R., & McLain Smith, D. (1985) Action Science: Concepts, Methods, and Skills for Research and Intervention. San Francisco, CA: Jossey-Bass in 1985 and remained in print until 2000. Brookfield, S. D. & Preskill, S. (1999). Discussion as a Way of Teaching. San Francisco, CA: Jossey-Bass. Dillon, J. (1994). Using Discussion in Classrooms, Buckingham, England: Open University Press Facilitating LOS Debriefing: A Training Manual http://ntl.bts.gov/lib/000/900/962/Final_Training_TM.pdf Mort, T.C. & Donahue, S.P. (2004). Debriefing: The basics in Simulators in Critical Care and Beyond, Dunn, ed; (p76-81). Society of Critical Care Medicine. Seropian, M. A., Brown, K. Gavilanes, J. S., & Driggers, B. (2004). Simulation: Not just a manikin. Journal of Nursing Education, 43(4), pp. 164-169. Turner, S.H., & Kurtz, W.D (2008). Debriefing for Patient Safety. Patient Safety & Quality Healthcare, (November/December 2008).