Debriefing in Simulation
Garth Meckler, MD, MSHS
Mary Anna Gordon, DNP, RN
Overview
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Is Debriefing Important?
History
Theory
Goals and Objectives
Considerations
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Elements
Approaches & Styles
Methods & Strategies
Tips / Tricks / Adjuncts
Practice
Is Debriefing Important?
• Feedback is the most
important feature of
simulation-based medical
education
– Issenberg et al. Features
and uses of high-fidelity
medical simulations that
lead to effective learning: a
BEME systematic review.
2005.
• Perceived skill of the
debriefer has the highest
independent correlation
to perceived overal
quality of the simulation
– Wilhelm J. Survey of
simulation participants.
1991
History
• Military
– After-action review
• Aviation
– Response to accidents in 1970s
– Pre-flight briefings / Post-flight debriefings
• Psychology
– Experiments using deception
– Staff processing
Theory
• Andragogy
– Adult learning
– Malcolm Knowles
• Kolb Learning Cycle
Experience
Simulation
Experiment
Reflect
Translation
Debriefing
Conceptualize
Reflection
Theory
• Circumplex Model of Emotion
– Russel and Feldman-Barrett
Activation
Tense
Alert
Nervous
Excited
Stressed
Elated
Upset
Happy
Unpleasant
Pleasant
Sad
Content
Depressed
Serene
Bored
Relaxed
Fatigued
Deactivation
Calm
Goals
• Facilitate learning through insight,
understanding, and meaning
– Safety
– Respect
– Curiosity
• Tied to educational goals of the experience
Objectives
• All
– Provide a safe, activating environment for learning
• Debriefer
– Elucidate the thoughts and actions of the participants
– Impart critical knowledge, skills, and attitudes
– Evaluate the educational experience and strategy
• Participants
– Improve insight, knowledge, skills, and attitudes
– Improve performance performance in similar
situations
Considerations
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Educational goals and objectives
Learners
Teachers
Time
Timing
Setting
Elements
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(Pre-briefing)
Emotions / Reactions (Impact)
Events (Process)
Explanation / analysis (Reflection)
Information (Didactic)
Applicability (Relevance)
Evaluation
Approaches
• Three Levels of Debriefing (Dismukes,
Aviation Model)
– High: participants debrief themselves with
minimal guidance
– Intermediate: increased instructor involvement
in analysis
– Low: Intensive instructor involvement
Styles
• Judgmental
– Goal: Make you to do
the right thing
– Assumption: I know
what went wrong
– Approach: blaming,
shame, statement of
“truth”
• Non-judgmental
– Goal: Avoid shame
– Assumption: as above
– Approach: kind,
gentle, lead learner to
my answer
– Carl Rogers: facilitator
as catalyst with
congruence,
acceptance, empathy
Example
Good Judgment
• CMS “Good Judgment”
– Goal: mutual learning without shame
– Assumptions: learner is smart and wants to
do the right thing
• Mistakes are puzzles, not crimes
– Approach: mutual respect, curiosity
• Advocacy: first person observation
• Inquiry: uncover learner’s frame
CMS Debriefing Process
• Reactions Phase
– Process emotions
– Plus/Delta
• Understanding Phase
– Explore “Frames”
using advocacy/inquiry
– Teach through
modeling and didactics
• Summary Phase
– What went well and
didn’t
– Take home learning
points
– Real-world application
Example
Emotions & Plus / Delta
Example
Summary
Understanding Phase
• Learner Frames:
– The “minds’-eye” of the learner
• Assumptions, feelings, knowledge, awareness,
context, goals of the learner
Frame
Result
Uncovered
Action
Observed
Advocacy-Inquiry
• Advocacy:
– First person observation of an action or result
– Concern or judgment about observation
• “I noticed that you left the door to the child’s room open. I
am concerned that this might allow humans into our world
which could be very dangerous.”
• Inquiry:
– Question designed to explore learner’s frame
– “Clean Question”
• “What was on your mind when you walked through that
door?”
Practicing Advocacy-Inquiry
• Why didn’t you call
for help?
• You forgot to wear
gloves and a face
shield, are you trying
to get Hepatitis?
• I noticed you seemed to get
very busy as the code
progressed, and I thought you
could have used some
additional help. I’m wondering
where you were on that?
• I didn’t see you put on gloves
or a face shield. That’s the
most common mistake I see in
codes like this. I wonder why
that happens?
Tips and Tricks for the Difficult
Debriefing
• Prevention
– Pre-brief
– Prepare debriefing
guides
• Work in Teams
– Co-facilitator
• Body Language
• Validate Emotions
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Reflective listening
Normalize
Elaborate
Deflect
Additional Strategies / Methods
Strategies
• Self debriefing
• Peer debriefing
Methods
• Collaboration Script
• Written debriefing
• Video debriefing
Practice….
Practice…..