1. Debriefing in Medical Simulation Manu Madhok, MD, MPH Emergency Department Children’s Hospital and Clinics of Minnesota

2. Disclosures I have no financial disclosures or conflict of interest

3. Objectives Review Simulation and Debriefing background Describe debriefing for various goals Present debriefing components Introduce a medical debriefing tool Review a simulation session Practice debriefing using scripted debriefing tool Translate to clinical settings

4. Why Simulation To transmit knowledge, impart skills, and inculcate the values of medicine that will improve health outcomes Cooke, Irby, O’Brien. Carnegie Foundation Report: Educating Physicians: A call for reform of medical school and residency. 2010

5. Simulation Virtual realism Technique and not technology Goal is the transfer of skills Aviation industry

6. Simulation Based Learning Educating adult professionals Active participation increases learning effectiveness* SBL offers opportunities for structured experiential learning (includes practice and also thinking about it) Reflection on these learning events is part of experiential learning which is facilitated by Debriefing *Seaman, et al. Effective Strategies for Teaching Adults. Merrill, 1989.

8. Simulation: Bench/Book to Bedside

9. ?? See one, Do one, Teach one??

10. Debriefing Facilitated or guided reflection in the cycle of experiential learning

12. Why Debriefing Learner reactions Modification of attitudes Acquire knowledge and skills Change in behavior Practice change Patient outcome

13. Goal Specific Scenarios built around sentinel events to improve outcomes In-situ multi-disciplinary team Team work and communication skills Identify and address knowledge gaps

14. How do you make all of this happen? Teamwork divides the task and multiplies the success

15. TEAM Airway IV/IO/meds Monitor/Defib Compressor Recorder TEAM LEADER

16. Closed Loop Communication Team Leader: 1.Give request 2.Listen for verbal confirmation that request was heard 3.Awaits confirmation that task is completed 4.Confirms receipt of a completed assignment Team Member: 1.Confirms that request is heard 2.Inform team leader when task begins/ends 3.Verifies orders for drugs/treatments before given

17. Learner Oriented Procedural competence Utilizing multimedia tools like video Competence tool

18. POISE network

19. Credentialing Scenarios of procedural sedation Hybrid of hi-fidelity manikin and scripted actor

20. What is the evidence about debriefing? “Allows trainees to explain, analyze, and synthesize information and emotional states to improve performance in similar situations in the future” “Sharing critical judgments is an essential part of learning in simulation and debriefing” Rudolph (2007), Debriefing with Good Judgment, Anesthesiology Clin 25: 361- 76.

21. Components of Simulation- Debriefing Facilitator Participant Simulated Scenario Debriefing Recollection-Review Reflection with structure Renewed knowledge, skills and application

22. Role of Facilitator/Debriefer Sets the tone of the environment Sets expectations/objectiv es Determines if objectives were met Fosters dialogue Encourages reflection Recognizes gaps in learning Provides clear feedback and shares teaching points

23. Debriefing Session Set time and state your role as facilitator Brief introductions Review Objectives Share expectation of active evaluation of self and team performance Answer learner questions, Reflections Analysis: review decision-action-results Teaching points, examples and applications Conclusion with take home points and feedback from learners

24. Reflection/Self-Appraisal Asks open-ended questions in a tone of curious inquiry Uses non-directed phrases- I saw, I heard.. Promotes advocacy for engaging the learner Encourages the learner to provide his frame of reference

25. WHAT WENT WELL provide answer format How do you think the scenario went? ….I saw, I observed… How successful were you as a team? ….I noticed, I felt… Were directions clear? ….I heard…

26. HOW DID THE TEAM FUNCTION What was your role? Would you have performed better in a different role? What happened to the team during the simulation? Did team members act professionally? Did a leader emerge? Why/ why not? Was important information shared clearly?

27. WHAT ELSE HAPPENED Share domains What were some of your challenges? Communication- ? closed loop Shared Mental Model- ? situational awareness Resource Management- ?roles/expertise utilization How could you have been more effective? What were favorite/ least favorite aspects? What emotions did this experience trigger?

28. Process analysis Review decisions- actions-results Provide examples of positive interactions/ outcomes Link scenario to real life Review the teaching point/objective

29. How would this improve patient care What new knowledge did you gain? Are you comfortable with your skill level? How would this help you in practice? How will you apply this to the clinical setting?

30. Summarize These are the things you identified as going well… These are the things you identified as needing to work on… I saw improvements in the areas of…. Review take home points Thanks

31. Translation to Clinical Setting Learners who are debriefed in the clinical setting feel more supported by faculty, display improved knowledge and skill retention Best time is to do after a difficult interaction, code blue, procedure documentation.. as quality of feedback decays with time