Debriefing Sandra J. Feaster, RN, MS,MBA Program Director Center for Immersive and Simulation-based Learning (CISL) Stanford University, CA http://cisl.stanford.edu

DEBRIEFING IS THE “HEART AND SOUL” OF THE SIMULATED EXPERIENCE DEBRIEFING IS THE “HEART AND SOUL” OF THE SIMULATED EXPERIENCE - RALL, MANSER, & HOWARD, 2000

Objectives Identify the goals of debriefing Discuss the elements of debriefing Identify various approaches to debriefing Discuss the process of debriefing Formulate questions that assist students in self-reflection

Defining Debriefing Merrian-Webster (1945) 1 : to interrogate (as a pilot) usually upon return (as from a mission) in order to obtain useful information 2 : to carefully review upon completion <debrief the flight> Wikipedia, the free encyclopedia A debriefing or psychological debriefing is a one-time, semi-structured conversation with an individual who has just experienced a stressful or traumatic event. In most cases, the purpose of debriefing is to reduce any possibility of psychological harm by informing people about their experience or allowing them to talk about it.

Debriefing starts with the “Prebriefing” The instructor should be prepared Describe the purpose of the simulation The learning objectives How the process of debriefing will occur The learner will in turn: Know the expectations of the simulation Know the ground rules for their experience To understand that learners will come with their own experiences and frames

The Origins of Debriefing Military - the account individuals gave on returning from a mission Information analyzed and used to strategize for future missions/exercises (educational & operational) An aided process to reduce the psychological damage of a traumatic event

The Origins of Debriefing Critical Incident Debriefing Used to mitigate stress among emergency first responder CISD (Critical Incident Stress Debriefing)* Psychological debriefing (modified CISD)** Facilitator-led approach to enable participants to review the facts, thoughts, impressions and reactions after a critical incident Aim - reduce stress and accelerate recovery after a traumatic event Issue - concern that a single session approach may be inadequate is certain situations or with certain people * Mitchell, JT, Everly GS: Critical incident stress debriefing: An operations manual for the prevention of traumatic stress among emergency services and disaster workers (1993) **Dyregrov A : Caring afor heapers in diseaster situations: Psychological debriefing: Disaster Manage 1989

The Origins of Debriefing Experimental Psychology Participants who have been deceived as a part of a psychology study are informed of the true nature of the experiment Purpose is to allow dehoaxing to occur and reverse the negative effects of the experience

Educating Adult Learners via Simulation Much of learning from simulation is dependent on the impact of the experience. The event/experience needs to be relevant to make an impact. The learner must be moved by the event/experience to make an impact. EXAMPLE: Simulation with airway obstruction

Learning and Debriefing in Simulation I hear and I forget I see and I remember I do and I understand Confucius I trust and discuss Fanning, Gaba* * Fanning, RM, Gaba, DM, The Role of Debriefing in Situation-based Learning, Simulation in Healthcare, 2007

Debriefing Principles Foster Discussion in a non-threatening fashion Capture and leverage “golden or ah-ha” moments Seek similar real-world experiences Help apply the experience to real-world practice

Emotional Learning Emotional state can affect retention and activation How has the learner “framed” the experience

Reflective Practice Method used to scrutinize one’s own taken-for granted assumptions and professional work practices. The theory of reflective practice draws on cognitive science, social psychology, and anthropology. People make sense of external stimuli through internal cognitive “frames” (or frame of reference, mental models, etc), internal images or external reality. Rudolph, JW, Simon, R, Dufresne, RL, Raemer, DB. There’s No Such Thing as “Nonjudgmental” Debriefing: A Theory and Method for Debriefing with Good Judgment. Simulation in Healthcare, 2006

Frames are invisible to the instructor Debriefing leads to new frames FRAME ACTIONS RESULTS Debriefing changes later actions Rudolph, Simon, Dufresne & Raemer

Factors to consider in debriefing Objective of the exercise Complexity of the scenario Experience level of the learners Familiarity of learners with the environment Time available for the session Role of simulation in curriculum Individual personalities and relationships

Factors to consider from the facilitators point of view How many facilitators Has a plan been worked out in advance for how you will facilitate What are the personalities of the faciltators? Talkative, condescending, passive Where should the facilitator(s) sit?

Practical Aspects of Debriefing Setting - Physical Comfortable and private Think about seating style In-situ simulations Setting – Emotional Prebrief – set the expectations Confidentiality, role of the facilitator, role of the participant

Practical Aspects - Tips Questioning Open ended, non-judgemental Begin questions with what, how, or why to encourage deeper discussion Follow-up on participant comments Make the participant feel their contribution is important Consider the emotional impact of the exercise

Practical Aspects - Tips Include ALL participants Bring the quiet, withdrawn participant into the discussion (they have thoughts about what is happening, but may have trouble sharing) Reflect questions back to the participants Use silence appropriately (10 seconds is NOT too long) Be observant to the body language of the group or individual Understand group dynamics

Tips Pros – Cons – Alternatives Plus (+) Delta + Delta Example of good behaviors/actions Behaviors/actions that would change or improve in the future Easier Task or behaviors Behaviors or actions that were difficult

Things to Avoid Too much instructor talking Too much medical/technical Trap of “telling” to teach Avoid “personal” evaluation before the discussion ends Too much medical/technical Too judgementa/condescending Avoid interruptions Avoid “guess what I am thinking” Have an agenda, use cognitive aids……. be flexible

HELPFUL QUESTIONS Generic Repeating what the participant said to help reiterate a point, or open a discussion Relate the event to real life If participants are apathetic, address questions to them by name or go around the room in sequence Consider starting the debriefing by calling on someone other than the primary participant

HELPFUL QUESTIONS Generic statements What were the pros, cons, or alternatives to an action If this were to happen in real life, what might you do in the future Did you find the scenario challenging

HELPFUL QUESTIONS Opening lines How do you feel that went What were your first impressions when you arrived on scene Did you get an adequate handover Who/what where are other sources of information about the patient/scenario Who was the leader Did you ask for help

HELPFUL QUESTIONS Questions regarding task overload Were you and others in control of the situation What needed to be done How many people would this have required Ask the other participants how they felt – was the person or scenario overloaded

HELPFUL QUESTIONS Fixation Errors What did you think was happening Has anything like this happened in real life What made it difficult to think of other options or possibilities at the time

HELPFUL QUESTIONS Wrap up How did you hand over the scenario What were the take home messages of the scenario (+ delta or pro, cons, alternatives can help here) Review the aim of the simulation and how this can help in real life practice Give the participants the opportunity to discuss/recontact you if there are further questions

In Summary: Elements of a Good Debriefing Opened ended questions Positive reinforcement (but not false positive) Use of cognitive aids Good use of AV capabiity

In Summary: Elements of a Poor Debriefing Closed questions Criticism Focus on errors Focus on technical points Ignoring team work and communication Focusing too much on the AV or AV problems

Closing Thoughts Many of our peers feel that debriefing is the most important part of simulation training Many also feel that poor debriefing can harm the trainee Most feel a thorough prebriefing is essential Confidentiality and a non-threatening atmosphere is important

Thank You! sfeaster@stanford.edu http://cisl.stanford.edu