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

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– After-action review

• Aviation– Response to accidents in 1970s– Pre-flight briefings / Post-flight debriefings

• Psychology– Experiments using deception– Staff processing

Theory

• Andragogy – Adult learning– Malcolm Knowles

• Kolb Learning Cycle

Experience

Conceptualize

ReflectExperiment

Simulation

Reflection

DebriefingTranslation

Theory

• Circumplex Model of Emotion– Russel and Feldman-Barrett

Activation

Deactivation

PleasantUnpleasant

Alert

Excited

Elated

Happy

Calm

Relaxed

Serene

Content

Fatigued

Bored

Depressed

Sad

Upset

Stressed

Nervous

Tense

Goals

• Facilitate learning through insight, understanding, and meaning– Safety – Respect– Curiosity

• Tied to educational goals of the experience

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

Considerations

• Educational goals and objectives

• Learners

• Teachers

• Time

• Timing

• Setting

Elements

• (Pre-briefing)

• Emotions / Reactions (Impact)

• Events (Process)

• Explanation / analysis (Reflection)

• Information (Didactic)

• Applicability (Relevance)

• Evaluation

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

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

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

ExampleEmotions & Plus / Delta

ExampleSummary

Understanding Phase

• Learner Frames:– The “minds’-eye” of the learner

• Assumptions, feelings, knowledge, awareness, context, goals of the learner

ActionResultFrame

ObservedUncovered

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 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

Additional Strategies / Methods

Strategies

• Self debriefing• Peer debriefing

Methods

• Collaboration Script• Written debriefing• Video debriefing

Practice….

Practice…..