Taylor Sawyer, Marisa Brett Fleegler and Walter J. Eppich
© Springer International Publishing Switzerland 2016
V. J. Grant, A. Cheng (eds.), Comprehensive Healthcare Simulation: Pediatrics, Comprehensive Healthcare Simulation, DOI 10.1007/978-3-319-24187-6_3
Simulation Pearls
1. Debriefing is a key component of the simulation experi- ence and is essential to facilitate learning.
2. Limited evidence is available to guide the use of one framework or approach over any other. Some guidance is provided in terms of when certain approaches may be more useful and effective, but educators should pick the format and approach they are most comfortable with, and that they feel will be most beneficial to their learners based on the context and learning objectives of the training.
3. Creating a supportive learning environment is essential for effective debriefing. The use of co-debriefers, scripted debriefing and video-enhanced debriefing can also be uti- lized to augment the debriefing experience.
Introduction
“Simulation is just an excuse to debrief”
Author unknown
Debriefing is an essential component of simulation-based education (SBE). In this chapter, we offer pediatric simu- lation educators an overview of debriefing, provide several
frameworks to serve as a guide for debriefing practice, high- light the importance of creating psychological safety as a prerequisite for critical reflection, explore pediatric-specific considerations for debriefing, consider formal and informal approaches for educator faculty development simulation, and present methods of assessing debriefing quality.
Origin and Importance of Debriefing
Debriefing has been a critical part of healthcare simulation since its inception. Simulation and debriefing in healthcare education have expanded dramatically in recent decades, from the pioneering introduction of mannequin-based sim- ulation to present-day applications, ranging from skills- based competencies to teamwork and behavioral objectives [1]. Mirroring the impact of aviation and the military on healthcare simulation as a whole, debriefing itself has its genesis in military after-action reviews (AARs) and aviation post-flight reviews, augmented by important contributions from fields such as business communication and psychol- ogy [2]. Debriefing in healthcare supports both clinical and behavioral learning objectives [3, 4]. Crew resource man- agement programs in aviation debrief around issues of com- munication and leadership to specifically address the human factors that contribute to accidents [2]. These programs were the precursors to the domain of healthcare debriefing known as crisis resource management training in health care, which targets the human factors that contribute to medical errors [5]. The importance of this focus has expanded dramatically since the recognition of the role of human factors in medical errors in the 1999 report To Err is Human published by the Institute of Medicine [6].
The terms debriefing and feedback are sometimes used interchangeably; while they overlap, there are important dis- tinctions. Feedback is typically understood as a “unidirec- tional communication about the recipient’s behavior” [7] in which “specific information about the comparison between a trainee’s observed performance and a standard, [is] given
T. Sawyer ()
Department of Pediatrics, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, WA, USA e-mail: [email protected]
M. B. Fleegler
Department of Pediatrics, Division of Emergency Medicine, Harvard Medical School, Boston Children’s Hospital, Boston, MA, USA e-mail: [email protected]
W. J. Eppich
Departments of Pediatrics and Medical Education, Department of Pediatric Emergency Medicine, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
e-mail: [email protected]
with the intent to improve the trainee’s performance” [8], whereas debriefing is a “bidirectional and reflective” discus- sion [7]. The definition of debriefing has been elaborated as
“a facilitated or guided reflection in the experiential learn- ing cycle that helps learners develop and integrate insights into later action” [9]. Table 3.1 provides a comparison of debriefing and feedback. Both debriefing and feedback play a role in healthcare simulation, depending upon the desired learning objectives. Debriefing has broad applications to simulation-based learning; its usefulness is paramount for multidisciplinary and interprofessional training, more so- phisticated learners and more complex learning objectives.
A straightforward procedural task and novice learners may benefit both from more direct feedback as well as the guided reflection that formal debriefing offers, depending on the learning objectives, the available time, and the instructor’s preferences.
The critical role of debriefing in healthcare simulation is widely acknowledged. A widely attributed phrase in simula- tion education is that “simulation is just an excuse to de- brief.” This phrase captures the central role of debriefing in discussing and reflecting on experiences, central to the principles of adult learning theory and experiential learn- ing theory [10]. Kolb’s experiential learning cycle contains four phases: concrete experience, reflective observation, abstract conceptualization, and active experimentation [11]
(Fig. 3.1). Simulated patient care provides a chance for ac- tive experimentation, while debriefing provides a facilitat- ed and guided opportunity for reflection. Ultimately, Kolb frames this cycle as a learning spiral, with each iteration of experience and reflection deepening the learning.
The value of debriefing is also supported by empirical evidence. In a Best Evidence Medical Education (BEME) Collaboration review of the features of high-fidelity medi- cal simulation that result in effective learning, feedback was identified as the most important element [12]. In particular, feedback was noted to allow learner self-assessment and pro- gression to skill maintenance across a variety of feedback variables, including timing and types. The optimal debrief- ing strategies or methods for various types of SBE are not yet clearly defined by current research [7]. Utilizing debriefing in simulation offers the potential to bridge to an increased use of debriefing in real-life, daily clinical practice.
Frameworks and Approaches for Debriefing in HealthCare Simulation
Although debriefing is often described as a fluid and dy- namic process, a number of debriefing frameworks exist that help organize the process, particularly for the inexperienced debriefer. These overlapping, but distinct, strategies rely on a supportive environment to enhance a broad range of learning objectives from technical to nontechnical. An understand- ing of various frameworks and approaches to debriefing and feedback allows simulation educators to tailor debriefings to the learners’ stage of training, the time allotted for the debriefing portion of a simulation event, and the particular learning objectives of a particular session, as different de- briefing strategies may have advantages over others depend- ing on the setting [13].
Lederman describes seven common structural elements of the debriefing process [14]. These elements include (a) the debriefer, (b) the participants, (c) the experience, (d) the
Table 3.1 Comparison of debriefing and feedback
Debriefing Feedback
Purpose To review events and explain, analyze and synthesize
information To explain or clarify learning points
Context Learner-centered conversational format Instructor-centered teaching Direction of communication Two-way communication between simulation instructor
and participants One-way communication, with instructor feeding
information to student
Active
Experimentation Concrete Experience
Abstract
Conceptualism Reflective Observation
Fig. 3.1 Experiential learning cycle. (Adapted from Kolb and Kolb’s The Learning Way, Simulation Gaming, 2009 [11])
impact of the experience, (e) the recollection of the expe- rience, (f) the mechanisms for reporting on the experience, and (g) the time to process it. Over the past three decades, several frameworks to conduct debriefing and approaches to facilitate the debriefing conversation have emerged. Many of these debriefing frameworks adhere to Lederman’s basic elements and provide specific structure to the debriefing conversation in order to promote learning. However, some models such as learner-guided debriefing and intra-simula- tion debriefing diverge form Lederman’s paradigm and offer novel approaches for simulation debriefing.
Regardless of the debriefing structure, the basic purpose remains the same—to allow those who have had an experi- ence to reflect and discuss and analyze the experience and its meanings [14]. When facilitated effectively, the debrief- ing process provides a means of formative assessment by helping learners to identify, explore, and close performance
“gaps” [9]. The goal is for learners to improve poor perfor- mance and maintain good performance in subsequent events, both simulated and in the actual clinical environment [9].
Debriefing Frameworks
Establishing a contextual framework within which the de- briefing conversation unfolds helps both simulation par- ticipants and debriefers. When the debriefing conversation moves through defined phases, it promotes efficient use of time, keeps the discussion on track, and focuses on im-
portant topics. The frameworks are grouped based on the inclusion of a facilitator during the debriefing (facilitator- guided versus learner-guided) and the timing of the debrief- ing during the simulation session (post-simulation versus intra-simulation).
Facilitator-Guided Post-simulation Debriefing The most common debriefing model used in SBE is for a single trained facilitator or debriefer or a small number of trained facilitators or debriefers to facilitate a conversation with simulation participants in order to discuss the events that occurred during the simulation scenario (Fig. 3.2). Sev- eral frameworks describe a three-phase model, in which the debriefing conversation progresses through three sequential phases of discussion, each of which is aimed at a separate, yet important goal. Other frameworks involve more than three phases. Regardless of the number of phases, or purpose of each phase, the goal of all of the frameworks is to answer three basic questions: what happened, what was the effect of the experience on participants, and what does it mean [15].
Three-Phase Models
The most well-known three-phase frameworks for SBE de- briefing includes reaction, analysis, and summary phases [9, 16]. The first phase of this model (reaction) allows the
Fig. 3.2 Photograph of post- simulation facilitated debriefing conducted in situ in the intensive care unit. (Photograph courtesy of Taylor Sawyer)
debriefer and simulation participants to explore initial reac- tions, including emotional reactions, to the simulation expe- rience. Participants can blow off steam prior to completing the remainder of the debriefing. In this first phase, a common opening question to the debriefing conversation is “How did that make you feel?” In addition, relevant facts of the case are clarified. During the second phase (analysis) of the de- briefing, the focus is on what happened during the simula- tion and why participants performed the way they did. This phase can be further broken down into four steps, which in- clude: (a) identification of a performance gap, (b) providing feedback on the performance gap, (c) investigating the basis for the performance gap, and (d) helping to close the per- formance gap through further discussion and teaching [9].
It should be noted that a performance gap could also be a positive decision or behavior that should be reinforced with the participants or that some participants may not have been aware of during the scenario. The third phase (summary) is dedicated to distilling lessons learned and codifying the in- sights gained during the analysis phase.
Another three-phase approach, which includes gather, analyze, and summarize phases, is known as the G.A.S. ap- proach [17]. In this framework, the first phase (gather) al- lows the team leader to provide a narrative of the simulation events, with supplementation from the team. The second phase (analyze) is dedicated to learner-centered reflection and analysis of the actions during the simulation. During this phase, pointed questions are used to stimulate reflection and expose the learners’ thinking processes. The final phase (sum- mary) ensures that all the important learning objectives and teaching points were covered and to review lessons learned.
The G.A.S. debriefing framework is described as a “struc- tured and supported” format for post-simulation debriefing [17]. The structure is provided via the specific debriefing phases with related goals, actions, and time estimates. The support is provided by the inclusion of both interpersonal support, as well as the use of protocols, algorithms, and best evidence used to inform debriefing. The G.A.S. format for post-simulation debriefing has been adopted by American Heart Association (AHA) and has been incorporated in the pediatric advanced life support (PALS) course [18, 19, 25].
Multiphase Models
One multiphase approach to post-simulation debriefing is based on the US Army’s AAR [20]. In this framework, the debriefing conversation progresses through seven distinct phases, which include: Defining the rules of the debriefing, Explaining the learning objectives, Benchmarking perfor- mance, Reviewing expected actions during the simulation, Identifying what happened, Examining why things happened the way they did, and Formalize learning. The acronym DE- BRIEF can be used to remember the seven steps. It should be noted that several steps in this multiphase model over-
lap with those of the three-phase models described above, for example, allowing the group to discuss what happened, why it happened, and how performance could be improved next time. However, the AAR format is unique in its explicit outlining of learning objectives, its reliance of clear perfor- mance benchmarks, and the disclosure of what the simula- tion instructor/facilitator explicitly expected to happen dur- ing the simulation [20]. The inclusion of these phases in the debriefing conversation ensures a shared mental model during the debriefing. It also allows participants to clearly understand the intended learning objectives of the training and provides an opportunity to objectively compare their performance against a known standard. Through the explicit review of expected actions during the scenario, the AAR for- mat removes any ambiguity regarding the nature and intent of the simulation for the participants, prior to progressing on to the examination of what happened and why.
There is another multiphase model of debriefing in the debriefing framework, which is called “TeamGAINS” [21].
Using this framework, the facilitator guides the debriefing conversation through six sequential steps including:
1. Reactions of the participants, initiated with the question
“How did that feel?”
2. Debriefing of the clinical component of the scenario 3. Transfer from simulation to reality
4. Discussion of behavioral skills and relation to clinical outcomes
5. Summarization of learning experience 6. Supervised practice of clinical skills, if needed
The TeamGAINS framework integrates several approaches to debriefing the simulation team, including Guided team self-correction, Advocacy-Inquiry, and Systemic-construc- tivist (GAINS), which are discussed later in this chapter.
Use of the TeamGAINS format during debriefing has been associated with positive ratings of debriefing utility, psy- chological safety, and leader inclusivity [21]. The various approaches included in TeamGAINS can prove challenging for novice educators to master, but the approaches such as circular questions borrowed from systemic-constructivist ap- proaches offer advanced debriefers additional tools for their repertoire [22].
The empiric evidence base for debriefing in healthcare simulation is limited [23]. As such, educators currently have little guidance to suggest that any one framework for post- simulation debriefing described above is better, or worse, than any other. A summary of the different facilitator-guided post-simulation debriefing formats is provided in Table 3.2.
It is likely that any of the above frameworks can be effective, if used appropriately by well-trained and engaged simula- tion facilitators. In general, the various frameworks we have presented all share a structured format, which helps facilita- tors guide the debriefing conversation, make good use of the allotted time, and address the key learning objectives.
Table 3.2 Comparison of facilitator-guided post-simulation debriefing frameworks FrameworkPhasesPurpose of phase Good judgment [9, 16]ReactionsExploration of feelings and a time to share emotions (i.e.,“blow off steam”) Analysis Identify performance gaps, give feedback on performance gaps, investigate the basis for the performance gaps, engage in directed discussion and didactics
SummaryDistill lessons learned and codify insights gained during the analysis phase G.A.S. [17]GatherTeam leader provides a narrative of event, with supplementation from the team AnalyzePointed questions are used to stimulate reflection and shed light on the thinking process of the learners SummarizeVerify all important learning objectives and teaching points were covered and review lessons learned AAR [20]DefineDefine the rules of the debriefing ExplainExplain the learning objectives BenchmarkExplain performance standards (benchmarks) that were evaluated, if any ReviewReview expected actions during the simulation IdentifyIdentify what happened during the simulation ExamineExamine why things happened the way they did, and provide feedback on the performance gaps Formalize learningFormalize learning with a focus on what went well, what did not, and what participants would do differently next time TeamGAINS [21]ReactionsReactions of the participants, initiated with the question “How did that feel?” Clinical debriefingDebriefing of the clinical component of the scenario TransferTransfer from simulation to reality Behavioral skills discussionDiscussion of behavioral skills and relation to clinical outcomes SummarizationSummarize the learning experience Repeated practiceSupervise practice of clinical skills, if needed
Facilitator-Guided Intra-simulation Debriefing In order to maximize the time spent devoted to active and deliberate practice of key skills [24], recent reports describe methods for conducting debriefings during the simulation scenario—a debriefing method known as intra-simulation debriefing. Rather than waiting until the completion of the simulation case or scenario to debrief and provide feedback, intra-simulation debriefing occurs during the simulation sce- nario. This type of debriefing is provided through a series of short and highly focused, debriefing/feedback events, which occur any time when feedback or correction is required. One example is the combination of stop action debriefing with repeated practice on troublesome skills, named “rapid-cycle deliberate practice” (RCDP) [25]. RCDP focuses on the cor- rection of errors in real time. Using RCDP, the facilitator stops the actions of the participants any time an error occurs and uses a “pause, rewind 10 s, and try it again” approach to allow the participants to redo that section of the scenario again after the facilitator provides corrective feedback. The debriefing/feedback episodes focus on coaching the par- ticipants to maximize performance in real time. The basic principles of RCDP include (a) maximization of time learn- ers spend in simulation-based deliberate practice, (b) allow facilitators an efficient way to teach specific evidence-based approaches to medical care, and (c) foster psychological safety within the simulation environment [25]. RCDP has been shown to improve performance of pediatric residents during simulated pediatric cardiac arrest scenarios compared to historic controls trained using traditional post-simulation debriefings [25].
Learner-Guided Debriefing
A clear departure from the facilitator-led frameworks de- scribed above is a debriefing method in which there is no fa- cilitator to lead or guide the debriefing discussion, otherwise known as learner-guided debriefing. In this framework, the individual learners or teams debrief themselves. This type of learner-guided debriefing has been referred to as “self- debriefing” for individuals, [26] or “within-team debriefing”
when conducted by teams [27]. Reports of learner-guided debriefing describe the use of teamwork evaluation tools as a framework for reflection and formative self-assessment.
During learner-guided debriefing the participants use these teamwork tools to guide their own debriefing and discus- sions.
There is some evidence that learner-guided debriefing may be as effective as facilitator-guided debriefing. One study compared learner-guided to facilitator-guided debrief- ing for anesthesiology residents managing intraoperative cardiac arrest [26]. Residents were randomized to either self-
debriefing using a behavioral assessment tool (anesthesia nontechnical skills tool) or traditional instructor-led facili- tated debriefing. Both groups demonstrated improvements in performance from pre-test to post-test. There were no signif- icant differences in the degree of improvement between self- debriefing and instructor-led debriefing groups. A follow-up study compared the effectiveness of learner-guided debrief- ing using the Ottawa Global Rating Scale as a framework compared to facilitator-guided debriefing on team perfor- mance during a simulated anesthesia crisis scenario and once again found similar, but not statistically different, improve- ment in both groups [27]. These results suggest that effec- tive learning of nontechnical skills may be achieved equally through learner-guided debriefing without the aid of an in- structor, which could improve resource utilization and the feasibility of team-based simulation at a program level [27].
Practically speaking, it is important to highlight that the debriefing framework may be less important than the simple act of debriefing itself. It is likely that any of the debriefing frameworks described would be more beneficial at improv- ing performance over no debriefing.
Debriefing Approaches
There are several approaches to facilitate and optimize de- briefing conversations that operate within the frameworks elaborated above. We define approaches to debriefing as particular methods and conversational techniques utilized during debriefings, which are aimed at optimizing the provi- sion of information and maximizing the impact of the de- briefing experience. These approaches are different to the frameworks discussed above, which describe the organiza- tional context within which the debriefing unfolds and/or provides an outline for the conversational flow. Several pub- lished approaches to debriefing that can be used to facilitate the debriefing conversation and to engage pediatric learners are reviewed below.
Perhaps the best known approach to debriefing is the debriefing with good judgment approach [16]. The compo- nents of this approach include: (1) the conceptual model of reflective practice, which seeks to surface mental frames of mind that drove participants’ actions during the simula- tion session; (2) a debriefing stance that encourages simula- tion instructors to share their viewpoint, while at the same time allowing the participants to share their unique insights (i.e., the good judgment approach); and (3) utilization of the conversational technique known as advocacy-inquiry, a technique adopted from the business and organizational behavior literature. When using advocacy-inquiry, instruc- tors advocate their point of view and subjective judgment of an event that transpired during the simulation, then inquire about the participants frame of mind in relation to the event