1. Debriefing in Simulation
Garth Meckler, MD, MSHS
Mary Anna Gordon, DNP, RN

2. Overview Is Debriefing Important? History Theory Goals and Objectives
Considerations
Elements
Approaches & Styles
Methods & Strategies
Tips / Tricks / Adjuncts
Practice
Theory: Kolb Learning Cycle, Circumplex Model of Emotion, Androgogy
Approaches: Judgmental, Non-judgmental, Good judgment
Methods: Reactions, Plus/Delta, Advocacy/Inquiry, Team approach
Tips: The difficult debriefing
Practice: Monster’s Inc. and Communication Simulation

3. 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
Perceived skill of the debriefer has the highest independent correlation to perceived overal quality of the simulation
Wilhelm J. Survey of simulation participants. 1991

4. History Military Aviation Psychology After-action review
Response to accidents in 1970s
Pre-flight briefings / Post-flight debriefings
Psychology
Experiments using deception
Staff processing

5. Theory Andragogy Kolb Learning Cycle Adult learning Malcolm Knowles
Experience
Simulation
Adragogy:
Independent/self-directing
Experienced
Value learning that is relevant to their lives
Interested in immediate, problem centered vs. subject-centered approaches
Internally rather than externally motivated
Implications: involve learners in defining needs/goals/curriculum, support learners in carrying out their own learning plans, identifying resources, and critical self-evaluation
Kolb Learning Cycle: Experience (act of simulation), Reflect / Conceptualize (act of debriefing), Experiment (incorporate learning into real life)
Experiment
Reflect
Translation
Debriefing
Conceptualize
Reflection

6. Theory Circumplex Model of Emotion Russel and Feldman-Barrett
Activation
Tense
Alert
Nervous
Excited
Stressed
Elated
Upset
Happy
Unpleasant
Pleasant
Sad
Content
Depressed
Serene
Bored
Relaxed
Fatigued
Calm
Deactivation

7. Goals Facilitate learning through insight, understanding, and meaning
Safety
Respect
Curiosity
Tied to educational goals of the experience

8. Objectives All Debriefer Participants
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

9. Considerations Educational goals and objectives Learners Teachers Time
Timing
Setting
Debriefing should focus on meeting the educational goals and objectives
Consideration of the number of learners, learner background (multi-disciplinary groups) and individual learning styles
Consideration of the number and experience of teachers; who will debrief? Self-debriefing? Peer debriefing?
Time protected for debriefing (depends on the educational goals / objectives – less time for technical skills, more time for team skills / communication)
Timing: Immediate, delayed, longitudinal (blog, journal, reflection)
Setting: In situ, removed, remote. Physical arrangement – where to place the facilitators?

10. Elements (Pre-briefing) Emotions / Reactions (Impact) Events (Process)
Explanation / analysis (Reflection)
Information (Didactic)
Applicability (Relevance)
Evaluation
Pre-briefing: safety contract, orientation, goals / objectives, expectations, emotional valence, trust, suspension of disbelief
Anticipates / guides the debriefing
Can eliminate distractions, help focus learners
Provides insight into individual learning styles, group dynamics
Evaluation: Of learners and of educational experience, strategy

11. 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
High – Carl Rogers, teacher as catalyst, facilitator
Intermediate: Re-phrasing of learner’s observations/statements. Asking questions in multiple ways. Asking questions of multiple participants
Low: Directed discussion, specific questions and answers, recapping, agreeing, reinforcing, encouraging.

12. Styles Judgmental Non-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

13. Example

14. 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

15. 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

16. Example Emotions & Plus / Delta

17. Example Summary

18. Understanding Phase Learner Frames: The “minds’-eye” of the learner
Assumptions, feelings, knowledge, awareness, context, goals of the learner
Frame
Result
Action
Uncovered
Observed

19. Advocacy-Inquiry Advocacy: Inquiry:
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?”

20. 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?

21. 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
Safety contract, orientation, fiction contract
Co-facilitator: follow-up questions, re-directing, de-escalating
Reflect: So what I hear you saying is…Is that right?
Normalize: Almost everyone performs differently in these simulations than they do in real life….
Video: anectode about CPR and OBGYN Chair
Elaborate: I understand that you were feeling rushed. How come?
Deflect: ask a second participant to comment from their perspective. Change to a less charged topic. Share your own experiences

22. Additional Strategies / Methods
Self debriefing
Peer debriefing
Collaboration Script
Written debriefing
Video debriefing

23. Practice….

24. Practice…..