Debriefing in Simulation

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Debriefing in Simulation

• Garth Meckler, MD, MSHS
• Mary Anna Gordon, DNP, RN

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Overview

• Is Debriefing Important?
• History
• Theory
• Goals and Objectives
• Considerations

• Elements
• Approaches Styles
• Methods Strategies
• Tips / Tricks / Adjuncts
• Practice

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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

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History

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

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Theory

• Andragogy
• Adult learning
• Malcolm Knowles
• Kolb Learning Cycle

Experience
Simulation
Reflect
Experiment
Debriefing
Translation
Conceptualize
Reflection
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Theory

• Circumplex Model of Emotion
• Russel and Feldman-Barrett

Activation
Tense
Alert
Nervous
Excited
Elated
Stressed
Happy
Upset
Pleasant
Unpleasant
Content
Sad
Serene
Depressed
Relaxed
Bored
Calm
Fatigued
Deactivation
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Goals

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

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Objectives

• All
• 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

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Considerations

• Educational goals and objectives
• Learners
• Teachers
• Time
• Timing
• Setting

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Elements

• (Pre-briefing)
• Emotions / Reactions (Impact)
• Events (Process)
• Explanation / analysis (Reflection)
• Information (Didactic)
• Applicability (Relevance)
• Evaluation

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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

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Styles

• 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

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Example
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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 learners frame

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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 didnt
• Take home learning points
• Real-world application

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ExampleEmotions Plus / Delta
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ExampleSummary
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Understanding Phase

• Learner Frames
• The minds-eye of the learner
• Assumptions, feelings, knowledge, awareness,
  context, goals of the learner

Action
Result
Frame
Observed
Uncovered
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Advocacy-Inquiry

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

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Practicing Advocacy-Inquiry

• Why didnt 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. Im wondering where you
  were on that?
• I didnt see you put on gloves or a face shield.
  Thats the most common mistake I see in codes
  like this. I wonder why that happens?

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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

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Additional Strategies / Methods

• Strategies

• Methods

• Self debriefing
• Peer debriefing

• Collaboration Script
• Written debriefing
• Video debriefing

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Practice.
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Practice..