Keywords

Introduction

Facilitating a debrief is one of the most difficult skills to acquire in simulation. It is the phase that occurs after a simulation when the facilitators and learners come together to discuss and reflect upon the simulation experience. We often say that this is where the magic of learning happens. Educational theory supports the fact that when learners are guided through reflection, their experience will be transformed into new knowledge ready for application in the next experience. In this chapter we will review learning theory and a learner-centered approach that is crucial to debriefing. There are many methods for facilitating a debrief and limited evidence-based research that would favor one method over another, and therefore several debriefing methodologies will be highlighted and key themes presented. The debriefing methods are driven by the objectives, the type of simulation experience, the level of the learner, the environment, equipment, and the experience of the facilitator. The skilled facilitator uses the debrief to help learners reflect on their actions, identify gaps in knowledge and skills, reframe their decision-making, and improve teamwork. When planning a simulation curriculum, the debriefing phase should allow for extra time, and a practical rule to follow is at least twice the time as the actual simulation. A practical, structured guide to debriefing will be described. Several tools for debriefing and evaluating the facilitator will be highlighted.

Key Learning Points

  • Debriefing occurs after the simulation exercise and takes at least twice as long.

  • The premise of debriefing is experiential learning theory and reflective practice.

  • Simulation learning is solidified through reflection on action during the debrief.

  • Objectives must be clearly stated or visually presented.

  • There are many methodologies for simulation debriefing including advocacy-inquiry, plus-delta, rapid cycle deliberate practice, etc., but all involve structured feedback.

  • Psychological safety is essential for learning in a simulation debrief.

  • Diffusion of emotions is critical to allow for participants to partake in meaningful engagement in a debrief.

  • Checklists or protocols are useful tools to clinical debriefing.

  • Feedback to learners needs to be specific and depersonalized.

  • Teamwork debriefing is aided by TeamSTEPPS® concepts and tools.

  • Challenges to facilitating a debrief may be addressed by multiple strategies such as “parking lot issues” and co-debriefing.

  • Facilitating a debrief requires skill and practice.

Description/Background

Debriefing originates from the military and is used after a mission to collect, process, and disseminate information as well as to determine if members are ready to return to duty. Medical debriefing is commonly used after a major event such as a code, trauma, or patient death. The purpose is to review what went well and identify areas for improvement. It also provides healthcare workers an opportunity to talk about their emotions. Medical simulation is based on experiential learning theory, and the debriefing phase is where significant learning occurs through a process of guided reflection.

Experiential learning theory developed by Kolb states that “knowledge is created through the transformation of experience. Knowledge results from the combination of grasping and transforming experience.” He designed a four-stage learning cycle including “Do, Observe, Think, Plan” which highlights reflection and analysis [1]. Schön’s work on professional practice described two important concepts: “reflection in action” during an event and “reflection on action” after an event [2]. These educational theories lay the groundwork for adult learning through reflection during a simulation debrief.

Ericsson’s work on deliberate practice provides the basis for providing learners with multiple opportunities to refine skills. The key is that timely and specific feedback is provided between repetitions so that the learner may develop skills [3]. This concept is most applicable to learners developing new skills or moving from novice to expert level of skills.

Simulation debriefing of medical teams involves reflecting on teamwork and communication. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) is an evidence-based set of teamwork tools, aimed at optimizing patient outcomes by improving communication and teamwork skills among healthcare professionals [4]. It was developed by the Department of Defense and the Agency for Healthcare Research and Quality to integrate teamwork into practice. The tools and strategies as well as the entire curriculum are publically available and have been implemented widely through federal agencies and healthcare and academic institutions. The simulation debrief may be enhanced by reviewing examples of and opportunities for incorporating TeamSTEPPS® tools and strategies into clinical practice.

Evolving Evidence: Debriefing Methodologies

A significant work over two decades in the field of simulation debriefing has been done by Rudolf et al. [5] The focus of their work is on reflective practice and using good judgment when exercising a debrief. Rudolf’s debriefing model involves three phases: determining the conceptual framework of the learner, providing respectful performance evaluation, and using advocacy and inquiry to help the learner improve. These methods help promote the psychological safety that is necessary for healthcare workers to participate in a simulation exercise. By using the advocacy and inquiry method, the skilled simulation debriefer identifies actions that are questionable, helps the learner find cognitive frames or beliefs that caused the actions, and illuminates unintended consequences of these actions.

Others have provided us with a blended approach to debriefing by promoting excellence and reflective learning in simulation (PEARLS) [6]. Facilitators are often hesitant to provide critical feedback because of perceived negative effects on the learner. Eppich and Cheng devised a scripted approach to debriefing divided into four phases: reactions, description, analysis, and summary phases [6]. The reactions phase allows for emotional decompression of all learners. The description phase is a brief summary of the events and key issues for objectives of the debrief so that everyone is on the same page. The analysis phase can be done through learner self-assessment of what went well and what did not (plus-delta method), directive feedback on specific behaviors, or focused facilitation using the advocacy-inquiry method. The summary phase reviews the objectives and summarizes key learning points. The PEARLS framework and debriefing script allow for a standardized structure for facilitators at varying levels of expertise.

The American Heart Association (AHA) and the Winter Institute for Simulation Education and Research (WISER) collaborated to develop the structured and supported debriefing that is a learner-centered process for debriefing in three phases: gather, analyze, and summarize (GAS) [7]. This method is commonly used by the AHA for advanced cardiac and pediatric advanced cardiac life support program debriefing. It involves active listening to participants as they narrate their perspective of the simulation. This is followed by facilitated reflection with the aid of the recording of events and reporting observations. A summary phase reviews lessons learned.

Debriefing for Meaningful Learning (DML) by Dreifuerst uses the Socratic method of questioning to uncover the thought process related to action. Probing the assumptions, rationale, and consequences helps learners to reflect in, on, and beyond the simulation [8].

Another structured debriefing hybrid tool called TeamGAINS was developed by Kolbe et al. [9] It integrates three approaches: guided team self-correction, advocacy-inquiry, and systemic-constructivist techniques. The latter involves circular questions and a view from outside by a “reflecting team” at the interactions of participants. This is useful when larger groups are involved in simulation events and some are able to observe and provide their input. The steps in TeamGAINS involve a reactions phase, clarifying clinical issues, transfer from simulation to reality, reintroducing the expert model, and summarizing the learning experience. The authors were able to demonstrate improved psychological safety and inclusiveness using these methods.

The anesthetists nontechnical skills (ANTS) is a framework of four key skills categories: situation awareness, decision-making, task management, and teamwork/leadership [10]. It uses a four-point behavior rating scale for each category of the framework. The ANTS tool is used in simulation debriefing and in the workplace for providing constructive feedback. This tool has been disseminated worldwide for anesthetists.

“Rapid Cycle Deliberate Practice” is a debriefing and feedback methodology coined by Hunt et al. based on Ericsson’s work on deliberate practice [11]. Facilitators rapidly cycle between deliberate practice and directed feedback until skill mastery is achieved. It was developed for resident learning and applies the coaching principles of directed feedback followed by repetitive practice in order to maximize muscle memory learning in a short period of time. Simulations are interrupted for deviations from the gold standard then repeated until done correctly. Psychological safety and expert coaching were essential. These techniques resulted in improved mastery of procedural and teamwork skills for novice learners.

In summary, the main themes for debriefing a simulation include ensuring psychological safety, allowing for emotional decompression so that learning can occur, providing opportunities for all learners to participate, using methodology of reflective practice, promoting clinical expertise through practice, and optimizing teamwork and communication.

How to Implement: A Practical Guide to Debriefing in Simulation

Incorporating the extensive work of others, a practical guide to simulation debriefing in a systematic manner is presented here. In obstetrics and gynecology simulation programs, specific skill expertise and teamwork and communication are essential components of learning. The nature of our specialty is one of the high emotions as well as rapid, coordinated team actions during emergencies. Therefore this practical guide addresses several key components of the obstetrics and gynecology simulation debrief. Table 4.1 summarizes the structure, and Table 4.2 lists best practices.

Table 4.1 Structured debriefing guide for obstetrics and gynecology simulation faculty
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Table 4.2 Simulation debriefing best practices
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Address Learning Climate

Plan the location for the simulation debrief. Moving the group to another location may be beneficial when a simulation exercise involved significant action and emotion. This helps learners to decompress as they transition to a new environment. Address the learning climate by making sure that learners are all seated around a table or in a circle and at the same physical level. Limit distractions by silencing pagers and cell phones. The use of video debrief works well in this setting where everyone is able to view the simulation video.

If debriefing in the simulation room, have the learners move into a circle seated or standing so that everyone is on an equal physical level. The advantages of debriefing in the simulation room are that specific tasks may be demonstrated or repeated where the equipment is readily at hand. Co-debriefing works best if the facilitators are on opposite sides, so they can maintain eye contact and be part of the group.

It is very useful to have a board, tripod, or paper on a clipboard marked as “Parking Lot Issues.” Prepare the group to write down concerns that are brought up during the debrief that have to do with systems or operations that cannot be adequately addressed during the debrief and need further attention from other leaders. The facilitator may defer issues that distract from the team debrief and return with recommendations from leadership at a later time.

Diffuse Emotions

As soon as possible, diffuse the emotions. Experiential learning involves an emotional response to the actions, and learners coming out of a simulation exercise often experience a range of emotions. In order for them to enter the reflective phase of debriefing, the emotions need to be settled down. One way to do this is to ask everyone how they are feeling. Some learners will immediately speak, and others may remain quiet. Each participant should be encouraged to contribute. It is important to validate feelings and provide reassurance that in simulation we expect mistakes to happen. Reinforce psychological safety and “Vegas rules.” These are the rules of engaging in simulation and are usually discussed at the pre-brief. Participants are informed that the mistakes that inevitably happen in simulation exercises are not to be recorded or discussed outside of the simulation program. Set the agenda for the debrief by focusing on the objectives of the simulation.

Discuss Objectives of Debrief

Providing an outline and objectives of the debrief is important for learner participation and setting expectations. State that time will be allotted to reviewing any clinical issues followed by the majority of the debrief being spent reflecting on teamwork and discovering gaps in knowledge, skills, or attitudes. Engage learners by having them contribute to and agree upon the objectives of the debrief.

Clinical Debrief

Learners will often want to discuss clinical issues, and it is a good idea to address these early in the debrief. Using a clinical checklist helps to focus this part of the discussion. During the simulation, the facilitator may use the checklist or assign an observer to mark expected tasks based on standards of care. Clinical checklists and validated performance assessment tools are readily available through national organizations such as the American College of Obstetricians and Gynecologists patient safety checklists [12], patient safety bundles [13], and MedEdPortal [14]. The facilitator should also document specific clinical issues on paper or tag video during the simulation and refer to these. Review any issues related to medical equipment use or availability. Ask the learners if they have any clinical questions, and address them at this time. This is also a good opportunity for coaching through rapid cycle deliberate practice for clinical skills and coordinated teamwork required during emergency events.

Teamwork Debrief

Facilitators will debrief with the method that they are most comfortable. Advocacy-inquiry, plus-delta, and facilitated reflection are a few examples described earlier in this chapter. An important aspect of the team debrief is to use the term “we” such as “how well did we work as a team?” This reinforces team actions and communication. When addressing specific teamwork skills, it is helpful to focus on TeamSTEPPS® concepts. Posters or cards describing the acronyms and concepts of TeamSTEPPS® such as in Table 4.3 are useful visual aids during this phase of the debrief. Allow each person to speak about how they felt in their role during the simulation and if there was any information that they were missing or needed clarified. Suggest or have team members suggest TeamSTEPPS® concepts or tools that would have made the teamwork and communication more effective.

Table 4.3 TeamSTEPPS® concept card (Agency for Healthcare Research and Quality (AHRQ) http://teamstepps.ahrq.gov/)
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Summary and Closure

As the time approaches for the conclusion of the debrief, summarize concepts that were learned. This is a good time to review the objectives of the simulation and how they were met. The facilitator may want to list the key principles learned during the debrief or have each participant state their take-home points. Ensure that any “parking lot issues” are documented, and provide the group with assurance that items will be provided to the appropriate leaders as well as a follow-up communication. At the closure of the debrief, it is always a nice gesture to thank everyone for their participation and invite them to return for future simulation programs. If time permits, many facilitators prefer to repeat the simulation in order for learning concepts to be reinforced and for participants to leave the simulation feeling they performed “the ideal way.”

Examples of Debriefing Assessment Tools

There are a number of debriefing tools and checklists available to facilitators. Several are highlighted here. These include performance assessments of debriefing by raters and students and self-evaluation.

The Debriefing Assessment for Simulation in Healthcare (DASH©) tools were designed by the Center for Medical Simulation [15]. It is a six-element behaviorally anchored rating scale that provides feedback on evidence-based debriefing behaviors of the simulation facilitator. There are three versions of the tools: rater, instructor, and student (Figs. 4.1, 4.2, and 4.3). The DASH© tools are useful for faculty development in the skills of debriefing which take years of practice to become competent.

Fig. 4.1
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(a, b) DASH© tool for rater [16]. (Copyright 2018 Center for Medical Simulation, Inc., Boston, MA, USA, https://harvardmedsim.org/. All rights Reserved, used with permission)

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Fig. 4.2
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(a, b) DASH© tool for instructor [17]. (Copyright 2018 Center for Medical Simulation, Inc., Boston, MA, USA, https://harvardmedsim.org/. All rights Reserved, used with permission)

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Fig. 4.3
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(a, b) DASH© tool for student [18]. (Copyright 2018 Center for Medical Simulation, Inc., Boston, MA, USA, https://harvardmedsim.org/. All rights Reserved, used with permission)

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Six Elements of the Debriefing Assessment

  • Element 1 – Establishes an engaging learning environment

  • Element 2 – Maintains an engaging learning environment

  • Element 3 – Structures the debriefing in an organized way

  • Element 4 – Provokes an engaging discussion

  • Element 5 – Identifies and explores performance gaps

  • Element 6 – Helps a trainee achieve/sustain good future performance

Special Circumstances

There are several special circumstances that should be addressed in debriefing. Facilitators often become passionate about a particular topic and can hijack the debrief, which rapidly becomes a lecture. Facilitators much be cognizant of this pitfall and avoid it by using a structured format for the debrief.

When a facilitator notices a critical error that would impact patient safety, it is important to make this known during the debrief and immediately remediate. The ultimate goal of simulation is to improve patient safety, and despite the need for psychological safety, learners need to be corrected if there are performance gaps that may lead to patient harm. The facilitator may wish to spare the learner embarrassment in front of others by remediating in private; however it is more likely that other participants would benefit from the correction. Focusing specifically on the task and not the individual is a good way to address a critical error during a group debrief.

Occasionally there are difficult participants such as those who hijack the conversation, blame others, or refuse to participate. The skilled facilitator learns to read these signs and adjust the debrief accordingly. Steering the conversation away from hijackers, using “parking lot issues” boards, asking each participant to speak, and depersonalizing the discussion points are strategies that facilitators often use to help diffuse difficult situations.

Co-debriefing has its benefits and challenges. For interprofessional educational programs it is beneficial to have co-debriefers that can provide expertise to the learner groups. For example, physicians and nurses may be able to provide tips in practical skills and model professionalism in team behavior while co-debriefing. Best practices in co-debriefing include planning ahead, clarifying roles and methodology, common objectives, comparing notes on simulation observation, maintaining eye contact and strategic positioning during the debrief, asking questions through open negotiation, and conducting a co-facilitator debrief.

Summary

Debriefing in healthcare simulation is essential to learning but one of the most difficult components of a simulation. Learning achieved through simulation has improved retention due to the debriefing. Becoming a skilled facilitator takes significant expertise, patience, and practice. Debriefing is well grounded in educational theory including experiential learning and reflective practice. Active listening and a structured approach are best practices in debriefing. Though methodologies in debriefing may vary, the common themes include psychological safety of the learners, diffusion of emotion, standards of expertise, reflection and reframing, repeated practice, and optimizing teamwork dynamics. The purpose of simulation in healthcare is the guiding principle of improved patient safety. Debriefing solidifies this concept by identifying the gaps, finding the causes, and improving the healthcare team’s knowledge, skills, and attitudes.