Introduction to debriefing
Introduction
Debriefing is a lynchpin in the process of learning. Lederman described debriefing as a post-experience analytic process.1 Debriefing is a discussion and analysis of an experience, evaluating and integrating lessons learned into one's cognition and consciousness.2 Debriefing provides opportunities for exploring and making sense of what happened during an event or experience, discussing what went well and identifying what could be done to change, improve and do differently or better next time. Rall et al., regard debriefing as, “the heart and soul of the simulation experience.”3 This manuscript serves as an introduction to debriefing, covering a range of topics that include a brief review of its origin, the structure and process of debriefing—specifically in the context of simulation-based medical education, factors that facilitate debriefing and suggestions for successful debriefing. Critical incident stress debriefing (CISD), a specialized form of debriefing those involved in traumatic events, will be mentioned but not discussed in detail. However, an approach to debriefing immediately after real clinical events will be presented. The manuscript concludes with an evidence-based approach to evaluating debriefing skills of healthcare simulation instructors.
Section snippets
Brief history of debriefing
Debriefing has roots deeply embedded in the military and the aviation industry; and the fields of education, psychology and business. Debriefing's historical roots in the military stem from the 1940s during World War II (WWII) when the United States (US) Army Brigadier General and chief historian, Samuel Lynn Atwood Marshall, was one of several military historians tasked with documenting the events of WWII as they unfolded.4 He became frustrated by the usual process of reconstructing events
The role of debriefing in healthcare simulation
It was during the late 1980s that David Gaba, an anesthesiologist, translated aviation's “crew resource management” into “critical medical event management,” later shortened to “crisis resource management.”26 At the same time, Gaba et al. reintroduced fully interactive human patient mannequin simulators and used them for training anesthesiologists in simulated critical incidents within a comprehensive, simulated anesthesia environment.27, 28 Gaba, regarded as the grandfather of crisis resource
Experiential-learning and change theory
Adults learn through experience, by processing it and assimilating lessons learned into their world view. The more relevant the experience is toward achieving personal or professional goals, the more meaningful such learning is regarded.20 Kolb's theoretical framework of experiential learning is a cornerstone in the educational foundation of simulation-based education22 (see Fig. 1). In Kolb's cyclical model, learners enter through active engagement in a concrete experience.
The experience is
Structure and process of debriefing in simulation-based medical education
A sentiment shared among simulation educators is that simulation is a good excuse to debrief. There is no universally accepted gold standard approach to debriefing in simulation-based medical education (SBME). However, key structural elements of debriefing have been identified by Lederman that includes, (1) the debriefer, (2) participants to be debriefed, (3) an experience (simulated case), (4) the impact of the experience, (5) recollection, (6) report, and (7) time.2 (see Table 1.)
A few
Process of debriefing
Fanning and Gaba reviewed several models of debriefing, not specific to simulation in a medical context, as having anywhere from three to seven steps.34 Leading SBME experts at the Center for Medical Simulation in Cambridge, Massachusetts, have developed and refined a three-step model of debriefing in SBME (see Table 2) with a reactions phase, an understanding phase and a summary phase.51, 52
Step I. “The reactions phase”
The reactions phase occurs immediately after the simulation has ended and the participants have assembled for the conversation. Emotions may abound, so this phase allows for participants to vent and blow off a little steam. Immediate reactions may be verbalized on the way to the debriefing area so the debriefer should be alert for this opportunity to appreciate raw feelings being expressed by participants. As the debriefer listens to initial reactions of the participants, insight is gained as
Step II. “The understanding phase”
The understanding phase is the heart of the debriefing process. This is the inquiry and analysis phase during which the debriefer learns about what happened from the participants' perspective; and delves deeper to explore their frames of mind, appreciating what participants were thinking at a particular moment or juncture and gaining deeper insight as to what led them to behave, approach a problem, take action or execute a task in a particular way. Frames are the assumptions, goals, knowledge
Step III. “The Summary Phase”
The summary phase is the time to review lessons learned. The debriefer asks participants to share what they did well and what they thought went well in the case. Thereafter, the debriefer asks participants what they would do differently next time; what were their take-away points based on what they learnedl; or what they might try to implement in a future, real situation.
Debriefing with good judgment
Rudolph et al. stress the importance of debriefing with good judgment, sharing one's observations and expressing one's opinions and judgments based on the debriefer's expertise.51 Participants want to know what the debriefer thinks about their performance. Debriefing with good judgment is being tolerant but not colluding with participants by saying something was ok when it really was not. It does not assume a stance of certainty, righteousness or harsh criticism as with a judgmental approach.
Factors that facilitate effective debriefing
There are several factors that facilitate effective debriefing including building an open environment, focusing on key learning objectives, acknowledging the value of each participant and the importance of self-reflection, reassuring participants that debriefing is confidential and managing time constraints.1, 2, 3, 15, 34 Keys to building an open environment include:
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Ensuring staff have a “zone of safety,” a psychologically safe and private area for open discussion.
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Acknowledging the value of
Suggestions for successful debriefing
A successful debriefer understands the debriefing process, and knows when, where and how to debrief. An effective introduction and orientation of the participants to the simulation helps paves the way for a successful debriefing experience. Key components of an effective introduction include attending to personal comfort of participants, building trust and agreeing on non-negotiable mutual respect and confidentiality, providing a good orientation to the simulation environment, and agreeing on
Debriefing immediately after a clinical event
Debriefing has been classified in various ways, such as according to who leads the session, by a trained facilitator versus self or team-directed; or the context of the situation, a simulated versus a real clinical event.34 Thus far, facilitated debriefing of simulated cases has been the primary focus of this chapter. As critical as debriefing is after simulated cases, it also has tremendous value when performed after real events.1, 4, 17, 57, 58, 59, 60 Why debrief in real-time? Above all, it
Assessing skills of debriefers in healthcare simulation
Until recently, there have been no standardized instruments to assess the quality of debriefings in SMBE. In 2009, experts in healthcare simulation-based education at CMS developed a tool for evaluating and developing strategies and techniques for debriefing.64 The Debriefing Assessment for Simulation in Healthcare©, “The DASH©,” is a tool that was specifically designed for use by trained raters to assesses a debriefer's behaviors and actions that facilitate learning and change in wide range of
Conclusion
Debriefing is the cornerstone of the simulation experience. It is a unique opportunity for discussing and analyzing experiences, making sense of what happened and integrating lessons learned to improve performance and do better in the future. An effective debriefer understands the process of debriefing, the art and science of engaging adult learners and building an open environment that is psychologically safe and conducive for learning. He helps learners identify and explore performance gaps
Acknowledgments
The author is extremely grateful to the following experts in SBME for their valuable and profound contributions to the field of SBME and their friendship: David Gaba, Jeff Cooper, Dan Raemer, Jenny Rudolph, Robert Simon and Eduardo Salas.
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