The Art and Science of Debriefing: a Simulation Experience Mary Cantrell, MA PULSE Center – Director Arkansas Children’s Hospital

Debriefing The most important aspect of running any simulation - Debriefing “Simulation is just a good excuse to do debriefing” Dan Ramer

Learning Model Unconsciously – Incompetent Consciously - Incompetent Consciously – Competent Unconsciously - Competent

Your Best Teacher was… Smart Wise Caring Concerned Unspoken expert

How people practice Internal Frames EXAMPLES: Thanksgiving is a day I eat all my favorite food. Dancing makes me look goofy If I don’t leave work by 4:45 I will be stuck in traffic.

Learners Frames Feelings Assumptions Knowledge Stuff I know is true Stuff I learned in school

Frames shape actions Thanksgiving is a day I eat all my favorite food. – Eat all day – I can diet tomorrow. Dancing makes me look goofy – Don’t go near the party with a dance floor. If I don’t leave work by 4:45 I will be stuck in traffic. - Hurry all day to get it done because I don’t want to get home at 6pm.

Medical Frames & Actions Residents don’t have any power… and I can’t tell my attending what to do. When you do airway, you have to use an AMBO bag. I can’t find one and I think this patient is not going to make it. I just got out of school and everyone thinks I know what I am doing.

How do you define errors? Intentionally rational action Seemed like a good idea at the time, given the circumstances. Lack of knowledge

Our Basic Assumption Everyone participating in activities in the PULSE Center is intelligent, well trained, cares about doing their best and they want to improve.

Debriefers Job Help learner to surface their frames and analyze the impact on their actions. Be the UNSPOKEN EXPERT Facilitate open/safe discussion

Debriefing leads to new frames Debriefing changes later actions Frames Actions Results

Judgmental Statements & Questions Can anyone tell us where John made his big mistake? Does someone have a clue as to what went wrong with this patient? Setting them straight I’m right – You are wrong I know --- you don’t (essential failure in thinking) Truth------error (next time do it my way) I know the answer- can you guess what I am thinking? “pimping”

Non-Judgmental (???) I’m right – your wrong – but I don’t want to upset you. “Feedback Sandwich” Something soft (complement) Something meaty (criticism) Creates confusion Has hidden truths Consequences unclear

Debriefing with Good Judgment How did the learner make meaning of what happened Instructor “From what I know this happened in the simulation and this is where I saw the problems” Learner is also smart and well trained trying to do the best so… why did the learner take these actions? (they must have a good reason)

Errors are discussable Mistakes are made and recognized and then changes happen Source of learning happens when you know what happened and how it can be different Make mistakes discussable Enhance patient safety Let learners identify their own mistakes

Debriefing with Good Judgment Learner makes a mistakes Debriefer is genuinely curious Discuss what that looked like Learners feel worthwhile and intelligent Respectfully insert your expertise Frame changes can happen!

Debriefing is Discussion (not lecture!) The Debriefer should talk less Try only asking questions Get the learners to talk to each other Make it SAFE to discuss Be a facilitator; not a lecturer Closed ended questions – as appropriate Open ended questions

Three Elements of Debriefing Reactions Feelings Facts Understanding Explore deeper meaning Summary The take home message

Advocacy-Inquiry Advocacy – observation, statement, fact - neutral Inquiry – question or curiosity* *GENUINE Curiosity (you want to understand)

Successful Debriefing Genuinely interested – You see yourself as the good teacher not the good healthcare worker Pre-scenario briefing of expectations Reinforcing good practice Correct a limited number of errors Avoid excessive correction (people only remember 1 or 2 things - what is the take-home message?)

Successful, Con’t Stress key educational points Use playback so the learners can see themselves Talk less, facilitate more Be respectful of any learner criticism Use Advocacy – Inquiry Plus /Delta

Plus/Delta

Encounter Detractors Lack of purpose, objectives Excessive criticism, negative feedback Humiliating a team member Fixating on medical procedure

Encounter Detractors Underestimating the learner’s emotions/feelings Lecturing Hypercriticizing learner’s performance Allowing discussion to focus on limitations of simulation

Debrief Roadblocks This would never happen If this was a real case, I would have done things differently No matter what you say, I don’t agree with you

Good Debriefing Questions How do you think that went? What did you do well? How would you do this differently next time? How do you rate your communication between team members?

Good Debriefing Questions What was not done? How did you feel? What do you think happened? Has this ever happened to you in the past, how did you react?

Good Debriefing Questions What did you see happening? Would you have done the same thing as _____? What information was being used? Did you need anything that was not there?

Thank you! Mary Cantrell, MA University of Arkansas for Medical Sciences cantrellmaryj@uams.edu PULSE Center – ACH cantrellmj@archildrens.org