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Co-Debriefing for Simulation-based Education: Strategies for SuccessAdam Cheng1,2, Traci Robinson1, Helen Catena1, Wendy Bissett1, James Huffman1, Jon Duff3, Walter Eppich4, Jenny Rudolph5, Janice Palaganas5, Kate Morse6, Jose Maestre Alonso7 1KidSim Simulation Program, University of Calgary Alberta Children’s Hospital2The Royal College of Physicians and Surgeonsof Canada3Stollery Children’s Hospital4Northwestern University Feinberg School of Medicine,

Ann & Robert H. Lurie Children’s Hospital of Chicago5Center for Medical Simulation, Harvard University6Drexel University7Hospital Virtual Valdecilla

Objectives

•  Describe common challenges associated with co-debriefing

•  Identify, practice and apply proactive and reactive strategies for effective co-debriefing

Debriefing

•  Feedback and debriefing an essential component of simulation-based education1,2

•  What about co-debriefing?–  No studies3

–  No described methodology

1Issenberg et al. 2005 2McGaghie et al. 2010 3Cheng et al. 2014

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Co-Debriefing•  Defined as a debriefing

that is co-facilitated by 2 or more educators

•  Educators: may be from the same or different profession / discipline

Goal: Educators work together to manage the flow and content of discussion in an integrated and fluid fashion to promote

effective learning

Benefits of Co-facilitation

•  Larger pool of expertise•  Diverse viewpoints•  Cross monitoring•  Complementary styles•  Mutual support for

challenging situations•  Faculty development•  Model effective teamwork

Cheng A, Palaganas J, Rudolph J, Eppich W, Robinson T, Grant V. Co-debriefing for Simulation-based Education – A Primer for Facilitators. Simulation in Healthcare, 2015

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Case•  Septic Shock : 5 year old with fever•  Learning Objectives

–  Demonstrate effective management of septic shock–  Demonstrate effective team dynamics

Debriefing•  2 nurses, respiratory therapist, attending ER physician,

resident doctor•  1 MD facilitator, 1 nurse facilitator

Common Challenges•  Lack of knowledge of learning objectives (and how they

relate to various professions)•  Facilitators have different personal agendas•  Facilitator expertise is not optimally used•  Interruptions / hijacking train of thought•  One facilitator dominates discussion•  One facilitator speaks directly/only to learners from one

profession•  Open disagreement between facilitators

Cheng et al, Simul Healthc In Press

Failure to recognize and address challenges à discordance, power

struggle

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Apply Structure

How do new approaches to co-debriefing

fit within PEARLS?

Eppich et al, Simul Healthc In Press

!!!!!!!!!!!!!!!!

!!!!!!!

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REACTIONS!

!

DESCRIPTION!

!

SUMMARY!

Provide!Information!!(Directive!Feedback!and!Teaching)!

Discussion!and!!

Teaching!

May$shorten$if$learners$appear$to$have$a$shared$understanding$of$case$

Reactions!

Phase!

Eppich!&!Cheng!

Were!All!Learning!Objectives!Covered?!!YES!

Application!/!Summary!

Educator!Guided!Learner!Guided!

NO!

L

!

ANALYSIS!

$$$$$$$$$$$$$$$$$$1.$$$How$much$time$do$you$have?$ASK:$$$$$$$$$$2.$$$Is$the$rationale$evident?$$$$$$$$$$$$$$$$$$$3.$$$What$is$the$content$area?$

Shorter$Time$+$Rationale$

Content:$Technical/$Cognitive$

Select!Learning!Objective!

Less$Time;$Poor$Learner$Insight$$

Educator!Guided:!Teaching!

More$Time;$Good$Learner$Insight$$

Learner!Guided:!Discussion!

Revisit!Learning!Objectives!

Description!

Phase!

Select!Strategy!

Learner!!

SelfOAssessment!

Focused!Facilitation!(e.g.!AdvocacyOInquiry,!

Guided!Team!SelfOCorrection)!

Learner!Generates!

Objectives!(+/Δ) !

Analyze!

Performance!related!

to!Objective!

Less$Time$+/L$Rationale$

Content:$Undefined$

More$Time$L$Rationale$

Content:$Cognitive/$Behavioral$

Learners$may$reveal$key$areas$that$are$important$to$them$

Facilitator A

Facilitator A

Follow the Leader

Facilitator A or B

!!!!!!!!!!!!!!!!

!!!!!!!

!!!!!!!! !

!

REACTIONS!

!

DESCRIPTION!

!

SUMMARY!

Provide!Information!!(Directive!Feedback!and!Teaching)!

Discussion!and!!

Teaching!

May$shorten$if$learners$appear$to$have$a$shared$understanding$of$case$

Reactions!

Phase!

Eppich!&!Cheng!

Were!All!Learning!Objectives!Covered?!!YES!

Application!/!Summary!

Educator!Guided!Learner!Guided!

NO!

L

!

ANALYSIS!

$$$$$$$$$$$$$$$$$$1.$$$How$much$time$do$you$have?$ASK:$$$$$$$$$$2.$$$Is$the$rationale$evident?$$$$$$$$$$$$$$$$$$$3.$$$What$is$the$content$area?$

Shorter$Time$+$Rationale$

Content:$Technical/$Cognitive$

Select!Learning!Objective!

Less$Time;$Poor$Learner$Insight$$

Educator!Guided:!Teaching!

More$Time;$Good$Learner$Insight$$

Learner!Guided:!Discussion!

Revisit!Learning!Objectives!

Description!

Phase!

Select!Strategy!

Learner!!

SelfOAssessment!

Focused!Facilitation!(e.g.!AdvocacyOInquiry,!

Guided!Team!SelfOCorrection)!

Learner!Generates!

Objectives!(+/Δ) !

Analyze!

Performance!related!

to!Objective!

Less$Time$+/L$Rationale$

Content:$Undefined$

More$Time$L$Rationale$

Content:$Cognitive/$Behavioral$

Learners$may$reveal$key$areas$that$are$important$to$them$

Divide and Conquer

Ping Pong

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Pre$Debriefing+ Debriefing+ Post$

Debriefing+

•  Post%Debriefing.Huddle.

•  Facilitator.pre%briefing.

•  Se8ng.the.stage.for.the.learners.

•  Post%simula<on.touch%point.

•  Non%verbal.communica<on.

•  Listen,.observe,.reflect.•  Open.nego<a<on.•  Previewing.

•  Open.nego<a<on.•  Pulse.check.

•  Post%Debriefing.Huddle.

Proac1ve+Strategies+

Reac1ve+Strategies+

Cheng et al, Simul Healthc 2015

Proactive Strategies

Permissible Interruptions•  Verbally request or

provide permission to speak

Deliberate Transitions•  Use preview statement to

signal change in topic

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Proactive Strategies

Facilitator Prebrief•  Clarifying roles•  Ground rules•  Clinical / educational expertise•  Learning objectives•  Personal agendas•  Debriefing roles and

methodology•  Codebriefing approach

Proactive Strategies

Post-Sim Touchpoint•  Run scenario in “steady

state” for last 1-2 minutes•  Discuss observations

Setting the Stage for Learners•  Role of multiple facilitators,

background, expertise

Pre$Debriefing+ Debriefing+ Post$

Debriefing+

•  Post%Debriefing.Huddle.

•  Facilitator.pre%briefing.

•  Se8ng.the.stage.for.the.learners.

•  Post%simula<on.touch%point.

•  Non%verbal.communica<on.

•  Listen,.observe,.reflect.•  Open.nego<a<on.•  Previewing.

•  Open.nego<a<on.•  Pulse.check.

•  Post%Debriefing.Huddle.

Proac1ve+Strategies+

Reac1ve+Strategies+

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Proactive Strategies

Non-verbal communication•  Position yourself•  Make frequent eye contact

Previewing•  Verbalize intent to

transition to next topic, solicit input

Proactive StrategiesListen, Observe, Reflect•  Listen to discussion, observe

body language, reflect on optimal time to engage

•  Ask:–  “Will I be interrupting a line of

questioning if I speak now?”–  “Has the current topic of discussion

been brought to a close?–  “Will my contribution help to address

the issue at hand?”

Proactive Strategies

Open Negotiation•  Promotes transparent

communication between facilitators

•  A. Share train of thought•  B. Share reasoning•  C. Inquire about alternate

course of action

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Case•  Infant with increased intracranial pressure•  Requiring intubation and management of ICP

Exercise •  Conduct a facilitator pre-briefing•  Select a co-debriefing approach•  Conduct a debriefing with your co-facilitator and utilize proactive

strategies

Applying Proactive Strategies

Small Group Exercise – 15 minutes

Reactive Strategies

Open Negotiation•  A. Name they dynamic•  B. Normalize•  C. Generalize•  D. Engage learners to

identify solution

Reactive StrategiesPulse Check•  Clarify understanding with

“neglected” learner group–  “I am wondering if I can take a

moment to clarify….”

•  Check in with learners when one facilitator is dominating–  “I wondering if we can press the

pause button for a moment to see how this is resonating with the learners…”

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Case•  Adult with cardiac arrest•  Learners fail to detect pulselessness

Debriefing•  2 facilitators: lead facilitator (ER doctor), associate facilitator (ICU

doctor)•  Learners: pediatric resident, inpatient nurse

Applying Reactive Strategies

•  You will play the role of the associate / co-facilitator (ICU doctor)•  Apply open negotiation and/or pulse check to manage conflict with

your co-facilitator

Exercise

Small Group Exercise – 15 minutes

Pre$Debriefing+ Debriefing+ Post$

Debriefing+

•  Post%Debriefing.Huddle.

•  Facilitator.pre%briefing.

•  Se8ng.the.stage.for.the.learners.

•  Post%simula<on.touch%point.

•  Non%verbal.communica<on.

•  Listen,.observe,.reflect.•  Open.nego<a<on.•  Previewing.

•  Open.nego<a<on.•  Pulse.check.

•  Post%Debriefing.Huddle.

Proac1ve+Strategies+

Reac1ve+Strategies+

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Post-Debriefing Huddle

Facilitator Huddle•  Any issues? (discuss examples)•  Simulation scenario•  Co-debriefing approach•  Rules of engagement

Take Home Messages

•  Codebriefing is often accompanied by challenges

•  Proactive and reactive strategies can help facilitators overcome these common challenges