1. Debriefing Sandra J. Feaster, RN, MS,MBA Program Director
Center for Immersive and Simulation-based Learning (CISL)
Stanford University, CA

2. DEBRIEFING IS THE “HEART AND SOUL” OF THE SIMULATED EXPERIENCE
DEBRIEFING IS THE “HEART AND SOUL” OF THE SIMULATED EXPERIENCE - RALL, MANSER, & HOWARD, 2000

3. Objectives Identify the goals of debriefing
Discuss the elements of debriefing
Identify various approaches to debriefing
Discuss the process of debriefing
Formulate questions that assist students in self-reflection

4. Defining Debriefing Merrian-Webster (1945)
1 : to interrogate (as a pilot) usually upon return (as from a mission) in order to obtain useful information
2 : to carefully review upon completion <debrief the flight>
Wikipedia, the free encyclopedia
A debriefing or psychological debriefing is a one-time, semi-structured conversation with an individual who has just experienced a stressful or traumatic event. In most cases, the purpose of debriefing is to reduce any possibility of psychological harm by informing people about their experience or allowing them to talk about it.

5. Debriefing starts with the “Prebriefing”
The instructor should be prepared
Describe the purpose of the simulation
The learning objectives
How the process of debriefing will occur
The learner will in turn:
Know the expectations of the simulation
Know the ground rules for their experience
To understand that learners will come with their own experiences and frames

6. The Origins of Debriefing
Military -
the account individuals gave on returning from a mission
Information analyzed and used to strategize for future missions/exercises (educational & operational)
An aided process to reduce the psychological damage of a traumatic event

7. The Origins of Debriefing
Critical Incident Debriefing
Used to mitigate stress among emergency first responder
CISD (Critical Incident Stress Debriefing)*
Psychological debriefing (modified CISD)**
Facilitator-led approach to enable participants to review the facts, thoughts, impressions and reactions after a critical incident
Aim - reduce stress and accelerate recovery after a traumatic event
Issue - concern that a single session approach may be inadequate is certain situations or with certain people
* Mitchell, JT, Everly GS: Critical incident stress debriefing: An operations manual for the prevention of traumatic stress among emergency services and disaster workers (1993)
**Dyregrov A : Caring afor heapers in diseaster situations: Psychological debriefing: Disaster Manage 1989

8. The Origins of Debriefing
Experimental Psychology
Participants who have been deceived as a part of a psychology study are informed of the true nature of the experiment
Purpose is to allow dehoaxing to occur and reverse the negative effects of the experience

9. Educating Adult Learners via Simulation
Much of learning from simulation is dependent on the impact of the experience.
The event/experience needs to be relevant to make an impact.
The learner must be moved by the event/experience to make an impact.
EXAMPLE: Simulation with airway obstruction

10. Learning and Debriefing in Simulation
I hear and I forget
I see and I remember
I do and I understand
Confucius
I trust and discuss
Fanning, Gaba*
* Fanning, RM, Gaba, DM, The Role of Debriefing in Situation-based Learning, Simulation in Healthcare, 2007

11. Debriefing Principles
Foster Discussion in a non-threatening fashion
Capture and leverage “golden or ah-ha” moments
Seek similar real-world experiences
Help apply the experience to real-world practice

12. Emotional Learning Emotional state can affect retention and activation
How has the learner “framed” the experience

13. Reflective Practice
Method used to scrutinize one’s own taken-for granted assumptions and professional work practices.
The theory of reflective practice draws on cognitive science, social psychology, and anthropology.
People make sense of external stimuli through internal cognitive “frames” (or frame of reference, mental models, etc), internal images or external reality.
Rudolph, JW, Simon, R, Dufresne, RL, Raemer, DB. There’s No Such Thing as “Nonjudgmental” Debriefing: A Theory and Method for Debriefing with Good Judgment. Simulation in Healthcare, 2006

14. Frames are invisible to the instructor
Debriefing leads to new frames
FRAME
ACTIONS
RESULTS
Debriefing changes later actions
Rudolph, Simon, Dufresne & Raemer

15. Factors to consider in debriefing
Objective of the exercise
Complexity of the scenario
Experience level of the learners
Familiarity of learners with the environment
Time available for the session
Role of simulation in curriculum
Individual personalities and relationships

16. Factors to consider from the facilitators point of view
How many facilitators
Has a plan been worked out in advance for how you will facilitate
What are the personalities of the faciltators?
Talkative, condescending, passive
Where should the facilitator(s) sit?

17. Practical Aspects of Debriefing
Setting - Physical
Comfortable and private
Think about seating style
In-situ simulations
Setting – Emotional
Prebrief – set the expectations
Confidentiality, role of the facilitator, role of the participant

18. Practical Aspects - Tips
Questioning
Open ended, non-judgemental
Begin questions with what, how, or why to encourage deeper discussion
Follow-up on participant comments
Make the participant feel their contribution is important
Consider the emotional impact of the exercise

19. Practical Aspects - Tips
Include ALL participants
Bring the quiet, withdrawn participant into the discussion (they have thoughts about what is happening, but may have trouble sharing)
Reflect questions back to the participants
Use silence appropriately (10 seconds is NOT too long)
Be observant to the body language of the group or individual
Understand group dynamics

20. Tips Pros – Cons – Alternatives Plus (+) Delta + Delta
Example of good behaviors/actions
Behaviors/actions that would change or improve in the future
Easier Task or behaviors
Behaviors or actions that were difficult

21. Things to Avoid Too much instructor talking Too much medical/technical
Trap of “telling” to teach
Avoid “personal” evaluation before the discussion ends
Too much medical/technical
Too judgementa/condescending
Avoid interruptions
Avoid “guess what I am thinking”
Have an agenda, use cognitive aids……. be flexible

22. HELPFUL QUESTIONS Generic
Repeating what the participant said to help reiterate a point, or open a discussion
Relate the event to real life
If participants are apathetic, address questions to them by name or go around the room in sequence
Consider starting the debriefing by calling on someone other than the primary participant

23. HELPFUL QUESTIONS Generic statements
What were the pros, cons, or alternatives to an action
If this were to happen in real life, what might you do in the future
Did you find the scenario challenging

24. HELPFUL QUESTIONS Opening lines How do you feel that went
What were your first impressions when you arrived on scene
Did you get an adequate handover
Who/what where are other sources of information about the patient/scenario
Who was the leader
Did you ask for help

25. HELPFUL QUESTIONS Questions regarding task overload
Were you and others in control of the situation
What needed to be done
How many people would this have required
Ask the other participants how they felt – was the person or scenario overloaded

26. HELPFUL QUESTIONS Fixation Errors What did you think was happening
Has anything like this happened in real life
What made it difficult to think of other options or possibilities at the time

27. HELPFUL QUESTIONS Wrap up How did you hand over the scenario
What were the take home messages of the scenario (+ delta or pro, cons, alternatives can help here)
Review the aim of the simulation and how this can help in real life practice
Give the participants the opportunity to discuss/recontact you if there are further questions

28. In Summary: Elements of a Good Debriefing
Opened ended questions
Positive reinforcement (but not false positive)
Use of cognitive aids
Good use of AV capabiity

29. In Summary: Elements of a Poor Debriefing
Closed questions
Criticism
Focus on errors
Focus on technical points
Ignoring team work and communication
Focusing too much on the AV or AV problems

30. Closing Thoughts
Many of our peers feel that debriefing is the most important part of simulation training
Many also feel that poor debriefing can harm the trainee
Most feel a thorough prebriefing is essential
Confidentiality and a non-threatening atmosphere is important

31. Thank You!