Understanding the Debrief Process Professor Robert P. O’Brien Clinical Education Fellow Department of Medical Education School of Medicine Faculty of Medicine, Dentistry and Health Sciences

Adjunct Faculty – CAE Healthcare University Appointments Disclosures Adjunct Faculty – CAE Healthcare University Appointments University of Melbourne University of Western Australia Consultant – Belridge Park Editorial Board – BMJ STELI Immediate Past Chair – Australian Society for Simulation in Healthcare (ASSH) Education Committee - Society for Simulation in Healthcare (SSH) Advisory Boards – Simulation Centres Internationally

WHAT IS DEBRIEFING A conversation between two or more people to review a real or simulated event in which participants analyse their actions and reflect on the role of thought processes, psychomotor skills, and emotional states to improve or sustain performance in the future. Centre for Medical Simulation (Harvard)

Facilitated reflection in experiential learning1 Involves “the active participation of learners, guided by a facilitator or instructor whose primary goal is to identify and close gaps in knowledge and skills.”2 1Fanning and Gaba 2007 2Raemer et al. 2011

What educators are doing? Applying phases1 Provide directive feedback and teaching2 Ask learners to self-assess3 e.g. Plus-Delta (+/Δ); Pros-Cons-Alternatives Provide focused facilitation e.g. Advocacy-Inquiry4,5,6 1Steinwachs 1992 2Archer 2010 3 Fanning & Gaba 2007 4,5,6Rudolph et al. 2006, 2007, 2008

Comparative studies: Video vs no video Expert modeling Debriefing Research Comparative studies: Video vs no video Expert modeling Terminal vs concurrent Oral vs multimedia Self vs instructor-led In-person vs. web-based Limited vs extensive Technical vs cognitive Cheng et al. 2014

Effective debriefings Safe learning environment Honest but non-threatening approach Organized Dialogue (usually) Reflection and analysis of performance gaps Trainees shares his/her perspective Focus on improvement or sustaining excellence Simon et al. 2010 Ahmed et al. 2012 Arora et al 2012

Dieckmann’s model of the simulation setting Simulation Phases Setting Introduction Simulator Briefing Theory Inputs Scenario Briefing Simulation Scenario Debriefing Course Ending Dieckmann’s model of the simulation setting Dieckmann et, al. 2012

Should it be a cycle? Setting Introduction Simulator Briefing Theory Inputs Scenario Briefing Simulation Scenario Debriefing Course Ending

Kolb

Behaviorist Learning Theory Reflective Learning Theory Educational Theories Behaviorist Learning Theory Knowledge acquisition and Automated response (Content , knowledge) Reflective Learning Theory Internal Examination Constructivist Learning Theory Transference to new real situations Cognitive Learning Theory Restructuring understanding through repetition, reinforcement and feedback

Adult Learning Principles Have prior learning and experience Are self directed learners Learn most effectively when they perceive a need for learning Prefer problem-centred approaches Self Evaluation Require Feedback Value experiential learning opportunities

LEARNING SYSTEM FEEDBACK LOOP Objectives Course Material Simulation Debrief LEARNING SYSTEM FEEDBACK LOOP

WHAT IS THE PURPOSE OF THE DEBRIEF Formative Feedback Reflective learning Part of a process of Experiential learning Develop metacognition

Actions Reactions WHERE DO WE AIM TO GO? Rudolph,J. Simons,R. Dufresne,R. Raemer,D Theres no such thing as “nonjudgmental”debriefing: a theory and method for debriefing with good judgement. Simulation in Healthcare Vol.1 No.1, Spring 2006 Actions Reactions

Aviation based debriefing After action Review PLUS (+) / DELTA (Δ) Aviation based debriefing After action Review Student centric approach Plus focuses on things that went well Delta focuses on things that need to change and how to change them All participants are expected to speak Simulation

PLUS (+) DELTA (Δ)

WISER GAS MODEL

Reactions Phase – Clear the air and set the stage for discussion HARVARD MODEL Three Phase model Phase 1 Reactions Phase – Clear the air and set the stage for discussion Feelings Facts

Understanding Phase – Analyse and Apply HARVARD MODEL Three Phase model Phase 2 Understanding Phase – Analyse and Apply Exploring – explore trainee’s perspective on scenario events Discussion and teaching – help move trainees to new perspectives, understanding and skills Generalise and apply- lessons learned to real setting

Summary – distill lessons learned for future use The Harvard Model Three Phase model Phase 3 Summary – distill lessons learned for future use What worked well What should be changed nest time Major ‘take-away’ take home message

PEARLS Combination of methods depending on the time available, experience, content of the session.

Where does the debrief aim to go? Rudolph,J. Simons,R. Dufresne,R. Raemer,D Theres no such thing as “nonjudgmental”debriefing: a theory and method for debriefing with good judgement. Simulation in Healthcare Vol.1 No.1, Spring 2006 Frames Actions Reactions

Assumptions Feelings Goals Rules Knowledge Base Situation Awareness Frames Assumptions Feelings Goals Rules Knowledge Base Situation Awareness Influence of context Frames

RUDOLPH – GOOD JUDEGEMENT TECHNIQUE Sharing critical judgements is an essential part of learning in simulation & debriefing There is no such thing as “non judgemental debriefing” - aim for “good judgement” “rigorous reflection” - bring to the surface both the clinical/ behavioural issues brought up by the simulation and the judgement of the instructor

Observation + Inquiry Curiosity ADVOCACY INQUIRY Observation + Inquiry What did I see and my point of view about it Curiosity Ask an open ended question about how the participant saw the issues Rudolph,J. Simons,R. Dufresne,R. Raemer,D Theres no such thing as “nonjudgmental”debriefing: a theory and method for debriefing with good judgement. Simulation in Healthcare Vol.1 No.1, Spring 2006

HARVARD MODEL Three Phase model Phase 1 Reactions Phase – Clear the air and set the stage for discussion Feelings Facts Phase 2 Understanding Phase – Analyse and Apply Exploring – explore trainee’s perspective on scenario events Discussion and teaching – help move trainees to new perspectives, understanding and skills Generalise and apply- lessons learned to real setting Phase 3 Summary – distill lessons learned for future use What worked well What should be changed nest time Major ‘take-away’ take home message

Resources

Professor Robert P. O’Brien Clinical Education Fellow Department of Medical Education School of Medicine Faculty of Medicine, Dentistry and Health Sciences rpobrien@unimelb.edu.au +61 419 597 245