Debriefing Scenario-Based Simulation Sessions

Models and Approaches

2015

UCSF Center for Faculty Educators & Kanbar Center for Simulation

Sandrijn van Schaik, MDDarren Fiore MDMehran Hossaini, DMD

Workshop Objectives

• Explain the role of debriefing in simulation

• Differentiate among three different approaches to debriefing.

• Apply commonly used debriefing skills.

• Manage basic pitfalls frequently encountered in debriefing.

Roadmap

• Debriefing: styles and approaches

• Group discussion: experiences

• Small group activity: video examples and practice

• Summary and evaluation

Debriefing: A Conversation After Simulation

• A process in which a team reexamines an encounter to foster development of clinical reasoning, critical thinking, judgment, communication and teamwork through reflection.

• Methodically review what happened and why.

• Clarifies and consolidates learning gained from an experiential exercise.

A Critical Aspect of Simulation

“In simulation, knowing how to debrief the learner’s experiences is as critical as creating scenarios and selecting the correct mannequin.”

J Perinat Neonat NursVol. 24, No. 4, pp. 302–309

Theoretical Framework

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Am J Surg. 2015 Jan;209(1):126-31.

The Essence of Debriefing• Debriefers make an implicit

comparison between desired and observed performance.

• Performance gap can be big or small.

• Describe assessment of this gap and inquire about its origins.

• Explore “frames.”

• Improve poor and reinforce good performance.

Debriefing: Aims

• Stimulate self-reflection.

• Share ideas, raise awareness of alternate approaches.

• Teach specific skills: procedural, communication, cognitive, teamwork.

• Behavior change.

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Pair-share exercise

• What challenges have you had/do you anticipate in debriefing?

When to Debrief• After a simulation session, learners are

emotionally charged.

• They analyze and criticize their performance.

• Validation of excitement / harnessing energy…

• Focusing it in a productive manner.

– Draw links between behavior and outcome; more likely to change future behavior.

• Consider changing location.

– Learners move from state of action to reflection.

Phases of Debriefing

Reaction/Decompression• Venting, emotional• Fear of judgment

Analysis/Reflection• Most important part• Explore learners’ mental

frameworks to provide insight into observed performance gaps

Summary• Reinforce learning

objectives• “Teaching riff”

• Permit these reactions• But shift to reflective

discussion

• Instructor uncovers frameworks

• Helps build alternates to improve performance

• Provide key take home points

Role of Facilitator(s)• Make it safe

– Create environment of trust and support

– Neither overly harsh nor falsely kind

• Make it stick– Promote reflective analysis

• Engage team members in debriefing process

–Make it last• Elicit commitment to change

• Identify performance gaps/areas of improvement Am J Surg. 2015

Jan;209(1):126-31.

Approaches to Debriefing

• Judgmental

• Nonjudgmental

• Debriefing with “good judgment”

Simulation in Healthcare. 2006;1(1):49-55.

Debriefing with Good Judgment

• Cornerstone: Assume the best intentions of learners, regard mistakes as a mystery to be analyzed rather than a crime to be punished.

Debriefing with Good Judgment

• Allows for evaluative judgment while respecting learner.

• Premise: Uncover mental frameworks that guide action, being employed by learners AND debriefer.

• Debriefer is aware of own framework, because this guides what they think should have happened.

• Debriefer ensures safe yet reflective environment, allowing learners to be more open to receiving alternative frameworks.

Frames Actions Results

invisible observable observable

Debriefing leads to new frames

Debriefing changes later actions

Frame: “I must have a pulse oximeter attached to know how the patient is breathing.”Action: Frantic search for a pulse ox.Result: Pt desaturates and descends into hypoxia.

Alternate Frame: “There are more reliable ways to assess breathing than pulse ox, like chest rise, lung auscultation, or color.”Action: Ignore missing pulse ox and assess clinical parameters of respiration.Result: Recognition of no chest rise, no breath sounds, and starting oxygen therapy.

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Individual frames

Made visible through debriefing

Unified actions

Debriefing with Good Judgment

• Pair advocacy (observation, statement) with inquiry (question).

• Formula:

– Observation (I noticed that…)

– Reasoning or concern (It seemed to me that…)

– Question (How did you see it?)

– Follow-up with teaching riff.

Example 1

Observation Reasoning or Concern

Question

“I noticed that you stepped away from the patient to look for a pulse oximeter…”

“…And it seemed to me that there were alternate means to assess respiratory status…”

“…I was wondering what your thoughts are?”

Judgmental “I was shocked that you walked away to look for a pulse oximeter for 90 seconds while the patient desaturated!”

Non-judgmental (guess what I’m thinking approach)

“So, what was the patient’s saturation when you went to look for a pulse oximeter?”

Example 2

Observation Reasoning or Concern

Question

“I heard you say ‘let’s not call a code yet’ at one point….”

“…I was concerned that the patient was deteriorating rather quickly…”

“…Help me understand how you decided that?”

Judgmental “I really would have called a code when the patient was deteriorating so quickly – I’m not sure why you hesitated.”

Non-judgmental (sandwich approach)

“I really liked how you delegated critical tasks. Next time, it might be beneficial to get more help in the room by calling a code. But I liked that took charge – it was clear to me that you were leading the code.”

Debriefing Using Advocacy-Inquiry

Adapted from: Anesthesiology clinics 25.2 (2007): 361-376.

Observation (Advocacy)

Reasoning or Concern (Advocacy)

Question (Inquiry)

I noticed that… I liked how you… How did you see it?

I saw that… It seemed to me that…

I was wondering what your thoughts are? Anyone else have a thought?

I heard you say… I was concerned that…

Help me understand how you decided that.

I got the impression that…

I’m curious how you felt about that.

In there anything you would do differently next time?

Some Practical Debriefing Tips

• Create a safe environment: set ground rules

• Take notes while observing simulation

• Link debrief to simulation and refer to 2-3 specific events that occurred. Choose wisely, with learning objectives in mind.

• Use first person.

– “I observed…”

– “I am concerned because…”

• Be genuinely curious; aim to discover learner’s perspective.

Some Practical Debriefing Tips

• Use short, open‐ended questions.

– “I am curious how you see it?”

– “What was happening at that point?”

– “How did you experience that?”

– “I wonder why?”

• Provide individual and team-oriented feedback.

• Reflection back to the group.

• Maintain silence; don’t dominate discussion.

Use of VideoNO evidence that it is betterPROS:

• Elimination of recall bias.

• Objective measure of the learner’s actions.

• No uncertainty (positive or negative).

• Pause, instant replay.

• Opportunity to see self from different perspective.

– Participant --> observer

• Data source (evaluate systems errors, time-sensitive events, teamwork).

Use of Video: CONS

• Intimidating

• Distracting

• Technical issues

• Personnel, time

• Cost

• Consent

• Possibly changes learners’ behavior (Hawthorne effect)

Evaluation Parameters for DebriefersParameters Goals

Length of scenario compared with length of DB

DB is approximately 3 times the length of the scenario

Length of time after scenario ends to when DB begins

5 min or less

# of learning objectives covered during DB Key learning objectives covered (2-4)

Number of debriefer questions compared to statements, number of open-ended questions compared with yes/no questions

> number of questions to statements depending on DB strategy. > open-ended questions than yes/no questions

Number of participant responses compared w/ number of statements/questions of debriefer

Participant vocalizations compared todebriefer , at least 2:1 or 3:1

Length of videotape segments played Play segments most impt to discussion of learning objectives (not whole tape)

Adapted from Center for Advanced Pediatric and Perinatal Education

Evaluating Debriefers: DASH

DASH Elements

Establishes an engaging learning environment

Maintains an engaging learning environment

Structures the debriefing in an organized way

Provokes engaging discussions

Identifies and explores performance gaps

Helps trainees achieve or sustain good future performance

Video Examples and Discussion

• What was done well?

• What could be improved?

• How might you do things differently?

– Practice using advocacy-inquiry

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Reflection

• Goal of simulation is teamwork, objectives center around teamwork skills such as role distribution, direct communication, closed loop communication

• What do you notice?

• How do you think the nurse and resident feel after this simulation?

Small Group Activity

• Groups of 4

• Practice debriefing: 1 debriefer, 2 team members, 1 observer

• Focus on specific language/words that you might use

Summary• Debriefing is the most important part

of a simulation exercise; it enhances learning opportunities and stimulates self‐reflection.

• Debrief in three phases: reaction, analysis and summary.

• Debriefing with good judgment aims to uncover learner’s frameworks and is performed using advocacy statements paired with inquiry.

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