Debriefing Continued: More on Medical Simulation Facilitation
Blog post by SimGHOSTS President Dr. Scott Crawford
Debriefing Continued: More on Medical Simulation Facilitation
Last month the discussion on debriefing focused on the concept and background for the use of debriefing to aid in simulation learning. As a refresher, debriefing is based on the learning theory described by Kolb where learning and knowledge are created through the integration of experience and practice. Debriefing should be safe for the learner and must be structured in a way so those participating feel safe to actively participate and reflect on all aspects of their performance, both good and bad. A masterful debriefer serves as a guide to the learners that helps them understand why they performed the way they did and how their background, knowledge and case perspectives can improve future performance. Debriefing is different from lecturing or teaching. While factual knowledge deficits can and should be addressed during this time as well, this “feedback” has a different structure and function than debriefing.
There are many debriefing styles and each has features that may be useful to assist with the process of self-discovery and adaptation. Most debriefing styles begin with a chance for learners to share and vent about the experience. This can serve as an opportunity to let emotions that were building up during a case be released. It also allows learners to separate themselves from the case and take a retrospective, if not introspective, view of their actions and the team’s actions. Listening to responses during this open-ended query about “How did the case go?” or “What did you think about that?” can give great insight into the general sense of the learners’ experiences, if it was not already clear. Perspectives shared during this time can often be used to help start a conversation and should be used in addition to the planned discussion from the case observation.
One tool that can help bring all learners into the debriefing discussion early and initiate active participation is a model of shared storytelling. In this method everyone is encouraged to share a single piece of information about a case. This serves as an icebreaker and supports the viewpoint of every person in the room, an especially powerful feature for interprofessional education (IPE) simulations where learners from different specialties may feel intimidated to speak out. The introductory query is phrased in this style - “Once upon a time there was a patient who…” - and then each individual is encouraged to share one detail or insight to paint a full picture from these individual descriptions. When the case is shared in this manner, it may help both the facilitator and the other learners identify what every individual experienced during the case, even if it was different from their own interpretation or understanding, this often leads to greater discussions during the remainder of the debriefing session.
One of the simplest debriefing methods is Plus Delta. In this method, learners review their performance and identify things that went well and things they would change. The positives are added to the “plus” side of a chart, and the items to change go on the “delta” side. This method is easy for those new to the concept of debriefing and helps reinforce the idea that a discussion of why things went well, to help reinforce positive actions, is just as important as trying to correct negative behaviors.
A second important technique is the use of advocacy inquiry in a method called “Debriefing with Good Judgment.”[i] This technique focuses on asking questions in a manner that supports decisions while encouraging deeper discussion about the motives behind each action. In this technique, an observation might be brought forward without judgment and then supported by a comment about its context.
“You said that circulation was the most important aspect of care in this case.” (advocacy)
“I liked that you obtained IV access early.” (advocacy)
These are both advocacy statements. Then there is inquiry as to why this action happened in this context.
Example: “What other methods can be used for cardiovascular support…” (inquiry)
The goal of the debriefer is to help the learner move between internal “frames” about perceptions, knowledge, feelings and assumptions and guide them to a change in behavior based on the exploration of these frames. A frame is a specific mindset or reason for interpreting an experience in a particular way. Helping the learner understand how and why they viewed the scenario in the manner they did will help them to move forward in the learning process and externalize experience beyond the specific scenario encountered.
Structured debriefing methods that give a script and help to guide the discussion through the use of a standardized format can help novice facilitators even though the experience may change with each case. One of the most widely used examples of this is the Gather, Analyse, Summarize format. This was popularized with the Pediatric Advanced Life Support (PALS) and Advanced Cardiac Life Support (ACLS) curriculum in 2011 that encouraged using this scripting method for debriefing the scenarios from these two courses. Specific training and information is available from the American Heart Association website.
The final method that will be described is the scripted debriefing method described by Walter Eppich and Adam Cheng: Promoting Excellence and Reflective Learning in Simulation (PEARLS).[ii] This script highlights many of the previously discussed features but was built to be flexible. The introduction script describes the goals, expectations and timeframe of the debrief. Then an open-ended reaction phase allows the learners to vent and share thoughts on the case. A brief overview of the case is allowed in the description to ensure all learners have a shared understanding of the case to be reviewed. Then the script breaks into one of three strategies and can flow seamlessly between these three options to allow appropriate coverage of all debriefing points. The three options are the Plus Delta described previously that encourages learner self reflection, advocacy-inquiry in a guided performance review, and finally an option for brief, directed feedback to teach critical points.
The PEARLS script is a good summary review of best practice guidelines for organizing debriefing and it incorporates three of the most commonly utilized debriefing tools: Plus Delta, advocacy-inquiry, and direct feedback. Knowing when these tools should be incorporated will improve the quality of a debrief, and having a better knowledge of debriefing techniques will improve the structure, culture and support of the activity.
One of the difficulties encountered by those trying to conduct debriefing is that few have received formal training. In an evaluation of nursing simulation programs in 2014[iii], only 31% of schools used a specific model for debriefing, only half of facilitators had ever received training and only about 1 in 5 had ever been given feedback on their debriefing technique. This is where the simulation technology specialist may be best suited to assist. Every vantage point is a valid one for participating in the debrief because every observation can help give insight into behaviors and reactions. In addition, the person in the control booth may be uniquely suited to critique and provide guidance to the facilitator on how to improve their debriefing technique because they know both the case specifics and have observed the learner performance.
Each simulation experience may feel intimidating to review because so many things can occur in a short session. Addressing everything from subtle body language to procedural technique and medical knowledge should be addressed. Having time to review everything and provide guidance may seem overwhelming. This is an area where I believe the simulation technology specialist may be of assistance. An extra set of eyes is always useful and behavioral interpretation is not something that requires content knowledge. The primary individual facilitating the debrief should be a content expert to ensure that factual knowledge and best practice guidelines are followed. Even so this, individual should use external literature, guidelines and protocols to support the expected care or behavior being addressed. These external references should be incorporated by the facilitator in to the case debriefing to support the case being reviewed.
In order to provide a systematic evaluation of the debriefing abilities of your faculty members, suggest reviewing their debriefing with the Debriefing Assessment for Simulation in Healthcare (DASH). This tool focuses on six aspects of debriefing:
- Establishes an engaging learning environment
- Maintains an engaging learning environment
- Structures the debriefing in an organized way
- Provokes engaging discussion
- Identifies and explores performance gaps
- Helps trainees achieve or sustain good future performance
The DASH tool provides a scoring system and information on what facilitators should strive for in each of these categories. This set of tools can be found here.
The only way to get better at debriefing is to practice; but reviewing the methods used by others and a careful reflection of your own sessions can help. Multiple debriefing methods may be appropriate for any given scenario, but some may be better suited than others depending on the learner type, experience, or knowledge/behavior to be addressed. Becoming adept at using a single method is a good place to start, but with increasing expertise transitions between methods can improve the quality of the debriefing. Using the expertise and observations of every person in the simulation will help to give a more complete perspective. I use simulation technology specialists, standardized patients and confederates to assist with debriefing discussions regularly and support and encourage this practice.
[i] Rudolph, J. W., Simon, R., Rivard, P., Dufresne, R. L., & Raemer, D. B. (2007). Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiology clinics, 25(2), 361-376.
[ii] Eppich, W., & Cheng, A. (2015). Promoting Excellence and Reflective Learning in Simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simulation in Healthcare, 10(2), 106-115.
[iii] Fey, M. K. (2014). Debriefing practices in nursing education programs in the United States (Doctoral dissertation).