Debriefing - Clinical Tree

What Is Debriefing?

The concept of debriefing after a challenging event has become commonplace in the health care simulation world, but debriefing as we describe it in this chapter includes a systematic discussion of any immersive event, real or simulated. We explore the debriefing process and its potential to spur reflection and affect learning across a broad spectrum of clinical activities and environments. Although simulations are especially appropriate for debriefing because they are planned exercises with known challenges and learning objectives, any clinical event can provide rich material for reflective learning. The skills described in this chapter can be used to help improve patient care and safety, enhance your own clinical expertise, and uncover systems issues in any environment.

For more than 20 years, we have worked to hone our skills in debriefing, and in this chapter we hope to introduce you to some of what we have learned. Although we will mention work by many others in health care and in other industries, this chapter—like much of the rest of this book—is largely a description of how the authors view and conduct debriefing. This is not intended to be a systematic review of the literature or an exhaustive description of all debriefing techniques. We will describe what we believe to be the most important concepts and issues and will concentrate on explaining our own approaches to debriefing.

The military originated the term “debriefing” to describe a process in which individuals systematically recount events after a mission to extract information and review lessons learned, whereas a “briefing” takes place as preparation before the mission. This meaning of debriefing was adopted by commercial aviation to describe postsimulation discussions. In 1990 our exploration of the aviation experience led us to adopt this postsimulation debriefing approach as the primary method of extracting the most learning out of simulations in anesthesia. This approach was then adopted widely in the rest of health care. Subsequently, the aviation industry produced training guides that delineated principles of debriefing. These sources are also of value to those working in health care. The debriefing practices we promulgated beginning in the early 1990s are consistent with subsequent aviation training guidance. ^,

What Is the Role of Debriefing in Simulation-Based Learning in Health Care?

Under what circumstances, especially following a simulation activity, is a debriefing warranted? Some types of simulation and part-task training, especially those dealing with specific technical or psychomotor procedures, may incorporate sufficient guidance in the simulation device itself to make direct involvement by an instructor unnecessary. In certain circumstances, an instructor may be able to provide technical guidance and feedback without a formal debriefing. For some simulation activities, especially with early learners, other pedagogical techniques, such as having a “teacher in the room” to guide, advise, and teach during the simulation scenario, may be more appropriate than a postevent debriefing. However, for many simulation activities, especially as attendees gain clinical expertise, allowing the participants to perform their (simulated) clinical work uninterrupted is important. A detailed discussion of what transpired, after the fact, adds to the learning experience. In concert with a major expert in aviation debriefing in 2006, we wrote, “When it comes to reflecting on complex decisions and behaviors of professionals, complete with confrontation of ego, professional identity, judgment, motion, and culture, there will be no substitute for skilled human beings facilitating an in-depth conversation by their equally human peers.” This intuition is borne out by the empirical study by Savoldelli and colleagues, which found that participants failed to improve their nontechnical performance in complex scenarios if they were not debriefed in this reflective fashion.

Of course, not all postevent debriefings are the same. How they are conducted, and by whom, can have a significant effect on both the learning process and the learning climate. For example, in Line-Oriented Flight Training simulation exercises, how participants felt about the overall quality of the simulation experience correlated significantly with their perception of the skills of the debriefer. Participants in health care simulations share this sentiment, in which the skill of the facilitators is thought to be a key factor in the learning process and in the credibility of simulation-based learning courses. Health care simulation instructors feel even more strongly that debriefing is the most important part of realistic simulation training, that it is “crucial to the learning process,” and if “performed poorly, can actually harm the trainee.”

Debriefing Differs from Traditional Teaching

Not surprisingly, debriefing is considered by many instructors of crisis resource management (CRM)-oriented simulation training to be the most challenging skill to perfect. Even after 24 years, the most experienced of us are still learning to debrief. The teaching environment in simulation-based learning is very different from that of the traditional classroom, and is also different from that of real clinical work. In the classroom, learning objectives are firmly set, whereas in real-life clinical situations they are dictated by clinical events. Simulations lie somewhere in between. Although learning goals exist, they may change depending on participant needs, on how the scenario progresses, or on the issues that surface during the debriefing phase itself. Especially with more experienced participants, debriefers strive to be perceived less as experts, and more as guides for participants as they work through their own self-directed and group-directed learning processes. In a debriefing discussion, the instructor often poses a few questions or comments to trigger discussion. Often the ideal question to pose may be one that “self-perplexes”—that debriefers themselves cannot answer. Having started the discussion, debriefers may comment at suitable moments to redirect or refocus the conversation. Participants speak at considerable length, back and forth with each other, often without verbal input from the instructor. We encourage debriefers to use open-ended questions directed to the group as a whole rather than just to participants who have played the most active roles. The opinions of all group members are sought, and where possible, quiet individuals are drawn out. When participants direct questions at the debriefer, we encourage the instructor to reflect them back to the group rather than provide the “answer” directly.

Debriefing is different than providing “feedback.” Feedback most commonly implies observations and advice by the teacher about the level of performance of the learner versus a reference level of expected performance. Although feedback can be conducted in different ways, we often see it performed as a one-way process that requires little input from the learner. Debriefing may include feedback, but debriefing implies a more nuanced interactive conversation exploring how and why a particular sequence of events occurred, and what techniques or choices could have been used to change the process and outcome. In the language of Kolb’s experiential learning theory, debriefing provides the occasion for reflection as the middle component of learning, in the cycle that begins with doing, and ends with consolidation of knowledge and skill.

To maximize participant-led discussions, our approach encourages debriefers to be impartial whenever possible, and to avoid making personal judgment calls on performance (e.g., “you did that really well” or “you need to improve that”), even when the participants seek a judgment. We also dissuade participants from making similar calls, always stressing the critique of the “performance” rather than the “performer.”

We encourage debriefers and participants to develop a tolerance for ambiguity, to allow instructors to relinquish some control of the learning process, and to empower the participant to lead the way. Instead of talking, debriefers must learn to listen and observe, to be sensitive to nonverbal nuances and cues, and to interpret behavior so as to optimally encourage engagement and direct discussion.

On the other hand, debriefers should try not to get too distracted formulating the perfect statement or question. Fostering an engaged conversation is much more important than aiming for the most efficient or the most probing inquiries. Focusing on active listening rather than on optimal questioning is the best way to keep the conversation going. In total, all these elements can be quite a departure for many educators. Adapting their teaching style to the debriefing approach can initially be very challenging, but the increased participant engagement is rewarding in the long term.

General Features of the Debriefing Process

Although there are a number of structural elements common to most debriefing sessions, the exact characteristics or value for these elements will depend on the curriculum and session. The key elements of debriefing sessions typically include:

The debriefer(s) (although the learners may sometimes act as their own debriefers )
The goals and objectives of the debriefing
The participants or learners to be debriefed
The characteristic of the event itself (usually a simulation scenario) and its impact on the participants in the session
The participants’ recollection of what transpired and the effects of hindsight bias
The timing of the debriefing relative to the scenario, and the debriefing’s phases
The physical environment of debriefing
Use of audio-video recordings in debriefing

The Debriefer

Who should debrief? What is the optimal number of debriefers? Do debriefers need to be subject matter experts in the area targeted by the simulation scenario? The answers to these questions start with the simulation session’s learning objectives. If the main emphasis of the activity is on CRM or teamwork skills, an expert in these fields can debrief very effectively without being a clinical expert. If there is more than one debriefer, each may debrief within their skill set or area of expertise. Depending on the complexity of the scenarios and the seniority of the participant population, a clinical expert trained in debriefing may also be required to fully address clinical questions. For example, in the Maintenance of Certification (MOC) in anesthesia simulation course for board certified anesthesiologists undergoing their 10-year MOC cycle, there is a requirement that at least one instructor (presumably one who takes part in the debriefing) is a board-certified anesthesiologist.

Debriefers who debrief in pairs may complement each other, relying on implicit reading of the flow of the debriefing or on subtle signals to coordinate their efforts. Debriefing in pairs can improve the flow when one debriefer is struggling to engage the group. It also serves as a method for honing the skills of inexperienced debriefers. However, it requires skill and tact on the part of dual debriefers for it to work effectively, and logistics may dictate that the number of instructors be limited. Hence solo debriefing is common; it can be very effective, particularly if the debriefer is skilled at using a variety of debriefing techniques. Although we typically think of debriefers as coming from the faculty pool, it is possible, in certain instances, for participants who are given appropriate guidance to act as their own debriefers. ^, In multimodality simulations, where mannequin-based simulations also include standardized patient (SP) actors, the SPs may also contribute to the debriefing, either “in role” or as debriefers, offering a unique perspective. The debriefing process is not rigid, and it should grow and evolve within programs, depending on the availability of facilitators, their level of expertise and experience, and the needs of the participant population.

Debriefing through facilitation is more than simply “making the discussion easier.” Ideally, it is a guided pathway to meaningful discourse that will encourage learning and behavior change. The exact level of facilitation and the degree to which the facilitator is involved in the debriefing process can depend on a variety of elements, such as learning objectives and overall curricular goals, the experience level of participants, and their familiarity with the simulation environment. It may also vary with the complexity of the simulation, the setting in which the debriefing occurs, and even the time available for debriefing.

The aim is to encourage the majority of the discussion and dialogue to stem from participants, in which the debriefer interjects only as necessary to keep the discussion on track to achieve particular learning objectives. Effective debriefers encourage participants by actively listening, often using nonverbal encouragement (e.g., nodding), or echoing statements made by participants.

Debriefers should be aware of the learning objectives prescribed by the curriculum, and also recognize that the stated objectives may not be those of the participants. Participant-driven learning objectives arising as part of a deep discussion may often override the preestablished learning objectives when they have special meaning to the learners and are not inconsistent with the overall goals of the curriculum. Adult participants are particularly cognizant of the relevance and applicability of what they are being taught, and may become more engaged when discussing issues that are pertinent to their needs. On the other hand, they may become frustrated or disengaged if they are not given the opportunity to discuss the issues that are most important and relevant to them.

The terminology regarding levels or degrees of facilitation can be confusing. In some sources (especially Dismukes and colleagues ^, ), a “high level” of facilitation describes debriefings that show “little input” by the instructor, favoring encouragement of conversation as described earlier. Conversely, “low level” facilitation means “much” involvement by the instructor, even to the point of lecturing. Varying levels of instructor input are appropriate for different types of simulations, different participant populations, and learning needs.

The Participants

The role of participants in the debriefing process differs considerably from that of the learner in the traditional classroom setting. Instead of being passive recipients of information, debriefing demands that participants demonstrate an ability and willingness to critically reflect on and analyze their own performance. This process involves exploring not only what happened, but why, and what lessons can be learned to improve future performance.

Participants may be homogeneous, from a single discipline, or diverse, with hierarchical elements in the case of combined-team exercises. They may have varying levels of expertise both in their clinical domains and in their prior exposure to simulation activities. All of these elements will affect the extent of instructor guidance and the styles of debriefing employed. Sometimes participants who are longstanding coworkers can be more forthcoming when they already feel comfortable conversing with each other. Others prefer to be anonymous among participants they do not know, needing some time to get used to their co-participants before they fully open up. The debriefer needs to quickly evaluate the group dynamics and adapt the debriefing style and techniques accordingly.

The Goals and Objectives of the Debriefing

The goals and objectives may vary considerably depending on the setting, resources, participant population, and desired outcome. Debriefings of early learners may be more focused on achieving clarity of what transpired clinically and on the available management choices, with nontechnical skills having a lesser focus. As the experience of participants rises, the focus of debriefing often shifts to a greater emphasis of CRM principles and systems issues, with a secondary focus on the medical and technical specifics of the scenarios. Similarly, short debriefings following announced in situ simulations (e.g., mock codes) typically focus on discrete learning objectives, often addressing systems issues that are pertinent to the in situ environment. Debriefings following a scenario conducted for research are often intended primarily to extract more information about the decision making of participants rather than to enhance their learning.

Characteristics and Impact of the Simulation Scenario

Scenarios designed with clear debriefing aims in mind usually lead to more success in achieving learning objectives and goals. The complexity of scenarios should be tailored to the level of experience of participants and to the relevant teaching goals. Anesthesia crisis resource management (ACRM) scenarios challenge participants to make complex decisions and to formulate, adapt, and execute difficult diagnostic and treatment plans both as individuals and teams. Scenarios with such complexity allow a rich discussion of different aspects of the performance during the debriefing. The number of participants engaged simultaneously in the scenario will also affect the debriefing (e.g., a single participant, a stratified group of participants with one individual in the “hot seat,” or clinical care provided “by committee” of an entire group).

Simulation demands a flexible approach to teaching and learning, forging educational opportunities from diverse, and perhaps unplanned, events or experiences. Should a scenario fail catastrophically (e.g., as a result of a serious simulator glitch), it may be appropriate to abort it, acknowledge the failure, and either forego the debriefing or conduct a discussion about the scenario case that was planned. Alternatively, when malfunctions allow the scenario to proceed in a credible clinical fashion, the instructor may decide to continue and to use the events of the scenario to achieve an evolving educational opportunity. Simulation is like live theater: often “the show must go on.” Having a good sense of humor about such events is usually appreciated by the participants.

Scenarios that are challenging to the “psyche” of participants or that probe ethical decision making require special attention, both in their design and the nature of the debriefing process. ^, These scenarios may include those in which the simulated patient dies or those in which a more junior clinician is required to challenge the judgment of senior personnel.

Some scenarios involve significant interaction with “family members” or nonparticipant “colleagues” who are acting as the confederate of the instructor. How these confederate roles are handled is important. If a major confederate role is played by a nonparticipant faculty member (either from the simulation team or from the real world of clinical care), it risks confusing participants. They may be unsure, either in the simulation or during the debriefing, whether the confederate is speaking in their simulation role or in their real world role. In such instances, participants should be informed of the confederate’s status either ahead of the scenario (if that will not alter its impact) or prior to the debriefing. In either case, it should be clear during the debriefing from which role the individual was (during the scenario) or is (in the debriefing) speaking. The debriefing of scenarios that knowingly challenge the participants’ psyche is best facilitated by instructors with the experience, training, and skill to conduct an appropriately nuanced debriefing and to recognize and handle any adverse reactions from participants. Programs should be prepared to refer participants for professional counseling should the need arise.

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