Debriefing in Medical SimulationManu Madhok, MD, MPHEmergency Department

Children’s Hospital and Clinics of Minnesota

Disclosures

• I have no financial disclosures or conflict of interest

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

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

Simulation

• Virtual realism• Technique and not technology• Goal is the transfer of skills

Aviation industry

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.

Simulation: Bench/Book to Bedside

?? See one, Do one, Teach one??

Debriefing

• Facilitated or guided reflection in the cycle of experiential learning

Why Debriefing

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

How do you make all of this happen?

Teamwork divides the task and multiplies the success

TEAMAirway

IV/IO/meds

Monitor/Defib

Compressor

Recorder TEAM LEADER

Closed Loop Communication

Team Leader:1.Give request2.Listen for verbal confirmation that request was heard3.Awaits confirmation that task is completed4.Confirms receipt of a completed assignment

Team Member:1. Confirms that request is heard2. Inform team leader when task

begins/ends3. Verifies orders for drugs/treatments

before given

Learner Oriented

• Procedural competence• Utilizing multimedia tools like video• Competence tool

POISE network

Credentialing

• Scenarios of procedural sedation• Hybrid of hi-fidelity manikin and scripted actor

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.

Components of Simulation- Debriefing

• Facilitator• Participant• Simulated Scenario Debriefing• Recollection-Review• Reflection with structure• Renewed knowledge, skills and application

Role of Facilitator/Debriefer• Sets the tone of the

environment • Sets

expectations/objectives

• Determines if objectives were met

• Fosters dialogue

• Encourages reflection • Recognizes gaps in

learning • Provides clear

feedback and shares teaching points

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

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

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…

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?

WHAT ELSE HAPPENED Share domains

• What were some of your challenges?

Communication- ? closed loopShared Mental Model- ? situational awarenessResource Management- ?roles/expertise utilization

• How could you have been more effective? • What were favorite/ least favorite aspects? • What emotions did this experience trigger?

Process analysis

• Review decisions- actions-results • Provide examples of positive interactions/

outcomes • Link scenario to real life • Review the teaching point/objective

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?

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

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