Debriefing in Simulation Garth Meckler, MD, MSHS Mary Anna Gordon, DNP, RN

Overview Is Debriefing Important? History Theory Goals and Objectives Considerations Elements Approaches & Styles Methods & Strategies Tips / Tricks / Adjuncts Practice Theory: Kolb Learning Cycle, Circumplex Model of Emotion, Androgogy Approaches: Judgmental, Non-judgmental, Good judgment Methods: Reactions, Plus/Delta, Advocacy/Inquiry, Team approach Tips: The difficult debriefing Practice: Monster’s Inc. and Communication Simulation

Is Debriefing Important? Feedback is the most important feature of simulation-based medical education Issenberg et al. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. 2005. Perceived skill of the debriefer has the highest independent correlation to perceived overal quality of the simulation Wilhelm J. Survey of simulation participants. 1991

History Military Aviation Psychology After-action review Response to accidents in 1970s Pre-flight briefings / Post-flight debriefings Psychology Experiments using deception Staff processing

Theory Andragogy Kolb Learning Cycle Adult learning Malcolm Knowles Experience Simulation Adragogy: Independent/self-directing Experienced Value learning that is relevant to their lives Interested in immediate, problem centered vs. subject-centered approaches Internally rather than externally motivated Implications: involve learners in defining needs/goals/curriculum, support learners in carrying out their own learning plans, identifying resources, and critical self-evaluation Kolb Learning Cycle: Experience (act of simulation), Reflect / Conceptualize (act of debriefing), Experiment (incorporate learning into real life) Experiment Reflect Translation Debriefing Conceptualize Reflection

Theory Circumplex Model of Emotion Russel and Feldman-Barrett Activation Tense Alert Nervous Excited Stressed Elated Upset Happy Unpleasant Pleasant Sad Content Depressed Serene Bored Relaxed Fatigued Calm Deactivation

Goals Facilitate learning through insight, understanding, and meaning Safety Respect Curiosity Tied to educational goals of the experience

Objectives All Debriefer Participants Provide a safe, activating environment for learning Debriefer Elucidate the thoughts and actions of the participants Impart critical knowledge, skills, and attitudes Evaluate the educational experience and strategy Participants Improve insight, knowledge, skills, and attitudes Improve performance performance in similar situations

Considerations Educational goals and objectives Learners Teachers Time Timing Setting Debriefing should focus on meeting the educational goals and objectives Consideration of the number of learners, learner background (multi-disciplinary groups) and individual learning styles Consideration of the number and experience of teachers; who will debrief? Self-debriefing? Peer debriefing? Time protected for debriefing (depends on the educational goals / objectives – less time for technical skills, more time for team skills / communication) Timing: Immediate, delayed, longitudinal (blog, journal, reflection) Setting: In situ, removed, remote. Physical arrangement – where to place the facilitators?

Elements (Pre-briefing) Emotions / Reactions (Impact) Events (Process) Explanation / analysis (Reflection) Information (Didactic) Applicability (Relevance) Evaluation Pre-briefing: safety contract, orientation, goals / objectives, expectations, emotional valence, trust, suspension of disbelief Anticipates / guides the debriefing Can eliminate distractions, help focus learners Provides insight into individual learning styles, group dynamics Evaluation: Of learners and of educational experience, strategy

Approaches Three Levels of Debriefing (Dismukes, Aviation Model) High: participants debrief themselves with minimal guidance Intermediate: increased instructor involvement in analysis Low: Intensive instructor involvement High – Carl Rogers, teacher as catalyst, facilitator Intermediate: Re-phrasing of learner’s observations/statements. Asking questions in multiple ways. Asking questions of multiple participants Low: Directed discussion, specific questions and answers, recapping, agreeing, reinforcing, encouraging.

Styles Judgmental Non-judgmental Goal: Make you to do the right thing Assumption: I know what went wrong Approach: blaming, shame, statement of “truth” Non-judgmental Goal: Avoid shame Assumption: as above Approach: kind, gentle, lead learner to my answer Carl Rogers: facilitator as catalyst with congruence, acceptance, empathy

Example

Good Judgment CMS “Good Judgment” Goal: mutual learning without shame Assumptions: learner is smart and wants to do the right thing Mistakes are puzzles, not crimes Approach: mutual respect, curiosity Advocacy: first person observation Inquiry: uncover learner’s frame

CMS Debriefing Process Reactions Phase Process emotions Plus/Delta Understanding Phase Explore “Frames” using advocacy/inquiry Teach through modeling and didactics Summary Phase What went well and didn’t Take home learning points Real-world application

Example Emotions & Plus / Delta

Example Summary

Understanding Phase Learner Frames: The “minds’-eye” of the learner Assumptions, feelings, knowledge, awareness, context, goals of the learner Frame Result Action Uncovered Observed

Advocacy-Inquiry Advocacy: Inquiry: First person observation of an action or result Concern or judgment about observation “I noticed that you left the door to the child’s room open. I am concerned that this might allow humans into our world which could be very dangerous.” Inquiry: Question designed to explore learner’s frame “Clean Question” “What was on your mind when you walked through that door?”

Practicing Advocacy-Inquiry Why didn’t you call for help? You forgot to wear gloves and a face shield, are you trying to get Hepatitis? I noticed you seemed to get very busy as the code progressed, and I thought you could have used some additional help. I’m wondering where you were on that? I didn’t see you put on gloves or a face shield. That’s the most common mistake I see in codes like this. I wonder why that happens?

Tips and Tricks for the Difficult Debriefing Prevention Pre-brief Prepare debriefing guides Work in Teams Co-facilitator Body Language Validate Emotions Reflective listening Normalize Elaborate Deflect Safety contract, orientation, fiction contract Co-facilitator: follow-up questions, re-directing, de-escalating Reflect: So what I hear you saying is…Is that right? Normalize: Almost everyone performs differently in these simulations than they do in real life…. Video: anectode about CPR and OBGYN Chair Elaborate: I understand that you were feeling rushed. How come? Deflect: ask a second participant to comment from their perspective. Change to a less charged topic. Share your own experiences

Additional Strategies / Methods Self debriefing Peer debriefing Collaboration Script Written debriefing Video debriefing

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