1. Taking Simulation & Debriefing to the Next Level
Taylor Sawyer, DO, MEd, CHSE-A
Director, Neonatal Education and Simulation-based Training (NEST) Program
University of Washington School of Medicine & Seattle Children’s Hospital, Division of Neonatology

2. Disclosure
Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing health care good or services related to the content of this CME activity
My content will not include discussion/reference of any commercial products or services
I do not intend to discuss an unapproved/investigative use of commercial products/devices

3. Learning Objectives
Describe the importance of debriefing in simulation-based education
Review core concepts in post-event debriefing
Discuss techniques for successful debriefing
Examine the benefits of ‘debriefing the debriefer’ to improve debriefing skills

4. The Importance of Debriefing

5. How important is Debriefing in Simulation-based Learning?
Very important
Important
Somewhat important
Undecided
Not important

6. Why is Debriefing Important?
Reflection on action is a critical part of experiential learning
Kolb
Allows time for self-exploration and feedback
Feedback/debriefing the most important part of simulation in the literature
McGaghie W, et al. A critical review of simulation-based medical education research: Med Educ Jan;44(1):50-63.

7. - Center for Medical Simulation, 2010
Debriefing Defined
‘‘process in which people who have had an experience are led through a purposive discussion on the experience.’’
-Lederman, 1992
“The act of reviewing a real or simulated event in which participants explain, analyze and synthesize information and emotional states to improve performance in similar situations”
- Center for Medical Simulation, 2010
Debriefing IS a type of feedback! Debriefing is specifically used in Crisis Resource Mgt (i.e. s/p real life codes or other significant medical stressors) and recently has been modified for use in medical simulation.
Goals of debriefing:
Allow trainees to make sense of, learn from and apply their simulation experience in future reality
Give accurate evaluative feedback while maintaining a psychologically safe environment Military (After Action Review)
Aviation
Pre-flight briefing & post-flight debriefing
Responses to crashes in 1970’s
Psychology
Debriefing History

8. Core Concepts in post-event Debriefing

9. What is Debriefing? Debriefing is not lecture
Debriefing is a facilitated discussion among team members about events that just occurred
The instructor’s job is to enable self-discovery among team members about
what went well, and why?
what needs improvement, and how?

10. Feedback vs. Debriefing
Feedback = provision of information
Debriefing = facilitated discussion
Feedback can occur during debriefing, but debriefing should only be the facilitator giving the participants feedback…
The amount of instructor feedback needed is inversely proportional to experience of team members

11. A Successful Debriefing
Creates an safe atmosphere where participants can analyze their own behaviors and skills
Addresses the most important learning objectives
what went well and what needs improvement
Engages all participants in learning
Results in improved performance

12. Techniques for successful debriefing

13. Preparing for Debriefing
What are your learning objectives for the scenario?
Teamwork/behavioral skills
Technical skills
Watch for unexpected learning opportunities that require discussion
‘Emergent’ learning objectives
These may not be on your agenda before the simulation, but are important to discuss

14. NRP Instructor’s Role During a Debriefing
Act as a conversation guide
Facilitate the debriefing process
Help learners identify the most important topics
Lead the discussion to the topic, if needed
Act as a resource for teamwork issues
Act as a resource for technical issues
Keep the discussion learner-centered
Hold your feedback, unless needed to guide learning

15. Basic Points for Debriefing Facilitators
Sit forward, do not cross your arms and legs
Be friendly and professional
Use humor carefully
Hold the team accountable for errors
Help them figure out why errors occurred, and how to prevent them next time
Use silence.
Count to five (or ten) before talking
Keep if BRIEF
5- 10 min max.

16. Psychological Safety
Critically important during simulation-based training
Requires a conscious effort, and planning
Suggestions:
Explicitly mention “safe learning environment” during pre-briefing, or debriefing
Employ the “Vegas Rule”

17. How to Facilitate the Debriefing Conversation?

18. The Beginning of the Debriefing

19. What’s the first question you ask during a debriefing?
“How did that feel? ”
“Can you briefly summarize that scenario? ”
“What do you want to make sure we discuss? ”
“What were you thinking…? ”

20. First Question: “How did that feel?”
Pros:
Allows people to unload emotion
Provides you with an opportunity to assess the feelings of the group
Establishes a safe environment for emotion
Cons:
Can take more time than you have available
Can result in emotional overload/distraction for everyone (“my daughter died in a code like this...”)
Those uncomfortable with “feelings” might disengage from the debriefing

21. First Question: “Can you briefly summarize that scenario? ”
Pros:
Provides opportunity to ensure everyone has the same shared mental model
Allow time for clarification about case, if needed
Focuses on medical aspects of the case (no emotions)
Cons:
No time for emotional off load
Typically requires follow up question to spark the conversation

22. First Question: “What do you want to make sure we discuss?”
Pros:
Learner centered
Allows self-identification of learning points
Can lead conversation rapidly to important topics
Saves time
Cons:
Impressions by a vocal few may influence the group
Conversation may stray from predefined learning objectives

23. The Middle of the Debriefing

24. Your Next Questions?
Progress through debriefing on some type of agenda
Examples:
Chronologic review of events
“Walk me through what was happening when you first approached the patient…”
Point-by-point according to learning objectives
“Let’s talk about communication during that case”
Observation by observation
“Who was the leader in this scenario?”

25. Suggested Debriefing Topics…

26. Why Behavioral Skills?
Team communication and leadership during neonatal resuscitation correlated with overall quality of the resuscitation and compliance with NRP steps
Behavioral Skill
Correlation
P value
Communication
0.236
0.007
Leadership
0.288
<0.001
Thomas EJ. Teamwork and quality during neonatal care in the delivery room. J Perinatol Mar;26(3):163-9

27. Why Behavioral Skills?
High behavioral skills scores associated with improved technical skills performance and faster times to key steps in resuscitation
Sawyer et al. Technical skills and behavioral skills in neonatal resuscitation. J Perinatology ;34(10):781-6

28. Don’t Let Important Points Fizzle - Dig Deeper!
“Tell us more about that…”
“What would have happened if…”
“Talk about that for a moment…”
“Who else observed this? What did you notice, and what were you thinking about?”
“Why was that helpful?”
“How could your team have helped you?”

29. Tips and Tricks Facilitate, Don’t Dominate
Before making a statement, think about asking a question instead
Be curious not accusative
Questions: Statements= 3:1
Avoid yes/no questions  What, How, and Why?
Trainee: Instructor speaking= 3:1
Don’t be afraid of silence!
Sort out your feelings: be at peace! Avoid, the “jeez, how careless! How could he miss something so important?!”
Set your stance: Assume the trainee meant to do the right thing. Remember the basic assumption!! Assume there is something useful for you to learn too. Avoid “hit and run” responses!
Pair advocacy and inquiry:
First advocacy: clearly state your observation, inference or concern then
Ask questions to find out more, find out why, begin a line of questioning!

30. Teaching During Debriefing?
Use the responses from participants to identify knowledge/performance gaps
Provide instruction IF needed to fill the gap
This is where feedback comes in!
Mental processes of participants
Insert Feedback Here
Rudolph et al. Sim in Healthcare. 2006

31. Using Video During Debriefing?
Good Points:
Saves time recounting events
Helps learners see what actually occurred
Helps learners see how their behaviors impacted others (positively and negatively)
Tips:
Do not show the entire video
Choose places that merit discussion
Pause the video during discussion

32. Debriefing with Video – Is it Helpful?
Sawyer et al. The effectiveness of video-assisted debriefing versus oral debriefing alone at improving neonatal resuscitation performance: a randomized trial. Simul Healthc Aug;7(4):213-21

33. Debriefing with Video – Is it Helpful?
Cheng A, et al. Debriefing for technology-enhanced simulation: a systematic review and meta-analysis. Med Educ Jul;48(7):

34. The End of the Debriefing

35. The goal is performance improvement, not perfection…
Ending the Debriefing
Conclude on a positive note
Ask summary questions:
“How has your teamwork improved?”
“What will you do differently next time?”
Consider polling each participant:
“What have you learned today?”
The goal is performance improvement, not perfection…

36. Debriefing the Debriefer

37. How to Improve Your Debriefing Skills?
Practice, Practice, Practice…
Use debriefing skills every day
Post-event clinical debriefing can utilize the same structure as post-event simulation debriefing
Video your debriefing and assess your own performance
Get feedback from your colleagues
“Debrief the debriefer”
COME TO THE ‘DEBRIEFING THE DEBRIEFER’ WORKSHOP THIS AFTERNOON!!!

38. Conclusions
Debriefing is THE most import part of simulation-based education
Post-event debriefing should follow a structured approach
Techniques for debriefing focus on guiding the conversation to achieve learning objectives & performance improvement
Getting feedback on your debriefings is important to improve skill

39. Questions? or