Betty Ishoy, MSN, RN-C
The Art and Science of Debriefing
October 12, 2011
Make up of the Audience
• Practice vs. Academia vs. _________
• Beginners vs. Intermediate vs. Super Users
• Listened to a debriefing seminar before vs. read about
debriefing vs. none
• Main purpose in coming to this session today?
My sim story
What is debriefing? De-what?
Learning Objectives
At the end of this session the participant
will be able to:
1. Identify the goals of debriefing.
2. Discuss the elements of debriefing that
improve outcomes.
3. Identify various approaches to
debriefing.
4. Discuss the process of debriefing.
Is Debriefing Really Important?
• Learning outcomes are dependent on feedback
and analysis at completion
• Key element to student learning (Cantrell,
Meakim, and Cash, 2008)
• Crucial --Students strongly believed immediate
debriefing enhanced learning—if wait it’s like
“wait until Dad gets home” for discipline (what
about waiting one hour?)
• Highly valued by students (Cantrell, 2008)
• In my experience, it is the MOST IMPORTANT
part of the whole simulation experience.
BEME study recommendations for effective learning
Study purpose: To review and evaluate the existing evidence, and to
distill several important features and aspects of simulators that will
lead to effective learning
• Provide feedback during the learning experience with the
simulator.
• Learners should repetitively practice skills on the simulator.
• Integrate simulators into the overall curriculum.
• Learners should practice with increasing levels of difficulty (if
available).
• Adapt the simulator to complement multiple learning strategies.
• Ensure the simulator provides for clinical variation (if available).
• Learning on the simulator should occur in a controlled environment.
• Provide individualized (in addition to team) learning on the simulator.
• Clearly define outcomes and benchmarks for the learners to achieve
using the simulator.
• Ensure the simulator is a valid learning tool.
BEME systematic review* Medical Teacher, Vol. 27, No. 1, 2005, pp. 10–
28 S. B. Issenberg et al.
http://informahealthcare.com.ezproxy.mcg.edu/doi/pdfplus/10.1080/014
21590500046924
Tanner’s Clinical Judgment Model
Paucity of research regarding best
practices of debriefing.
We could spend the whole time reviewing
debriefing literature.
Education of faculty is a critical element.
Debriefers
Thornton & Mueller-Hanson (2004) in their book,
Developing Organizational Simulations: A
Guide for Practitioners and Students,
emphasize the importance of using ‘‘trained
assessors to observe behavior, classify
behavior into the dimensions being
assessed, and make judgments about
participants’ level of proficiency on each
dimension being assessed’’ (p. 5).
Faculty training is imperative.
Role of Facilitator or the Debriefer
The facilitator is not a neutral observer
“The perceived skills of the debriefer has
the highest correlation to the perceived
overall quality of the simulation
experience” (Wilhelm, 1991—military)
Role of Facilitator or Debriefer
The facilitator:
1. Sets the stage for an engaging learning
environment
2. Maintains an engaging context for learning
3. Structures debriefing in an organized way
4. Provokes interesting and engaging discussions
and fosters reflective practice
5. Identifies performance gaps
6. Helps close performance gaps
Purpose of Debriefing
• Ensures learning objectives are met
• Helps students evaluate:
▫ their own performance
▫ the team’s performance (such as their
communication)
▫ their understanding of the patient, the pt
condition, and pt responses to the
interventions
• Helps students learn things they missed while
engaged in their own role (Peters & Vissers,
2004)
Goals Of Debriefing
1. Enhance critical thinking and problem solving
2. Encourage collaboration and communication
3. Comparing different perspectives increases understanding
(Peters & Vissers, 2004)
4. Reflect on emotions experienced (how do you students feel
when the simulator deteriorates or dies? Ovarian cancer,
end-of-life scenario)
5. Safe place to discuss experience without time constraints
and pressure
6. Develop information seekers by having students utilize
available resources (Don’t have to know all the answers,
but what the good resources are)
7. Correlate the simulated clinical experience (SCE) to realworld experiences, bridge the theory to practice gap
Not just what went well and what went wrong
Positives and negatives of debriefing
Components of a positive debriefing
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Student-Lead
Affirming
Reflective
Informative
Verbal/written debriefing (addresses both types of learners)
Professional yet Relaxed Setting
Visualization of self (video)
Open-ended questions
Enlightenment
Learning
No Blame Environment “no mistakes just opportunities for learning”
Knowledge transference
Closing the theory to practice gap
Getting students to see self as nurse/expert clinician
Positives and negatives of debriefing
Components of a negative debriefing
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Faculty-focused
Lecture-like
Off topic
Haphazard
Too quick (should be close to double the amount
of time in scenario)
Defensive student (video assists with this)
Differences among debriefing faculty (need to
develop consistency)
Disingenuous feedback (less than authentic)
Fractionation between curriculum, faculty, and
simulation
Accusatory or critical
How Is It Different From Post-conference?
• All students have shared the same patient
experience but from different viewpoints
• Functioned as a team caring for patient – can
they delegate and assign to each other?
• Individual roles contributed to patient’s care
• Video available
• Logs from simulator’s computer available
Best Practices as identified by other nurse educators
• Consistency among
debriefers
• Reflection/documentation
and video debriefing.
• Allow learner to lead
discussion
• Allow silence
• Review and see therapeutic
relationship, body
language
• Establish safe environment
(confidentiality)
• Debriefing double time of
simulation
• Prep before coming to
simulation
• Communication skills or
positive role models for
debriefers
• Start with a positive
• Debrief away from
simulation
• Empathy from faculty for
those in student role
• Live streaming
• Collaborative effort for
feedback
• Student-led
• Guided questions for
observers or faculty
• Immediate processing
Factors that inhibit debriefing as identified by other educators
• Not enough faculty
resources.
• The facilitator (wants to
teach everything) or a
negative faculty member
who talks down to student.
• Vulnerability, not feeling
comfortable enough to
open up and share
feelings.
• Faculty/facilitator
inconsistency.
• Lack of preparation from
the student.
• Lack of evidence or
“because I said so” or “let
me teach you this,
students”
• Perceived hierarchy
Starting with negatives
Too many students
Not enough physical space
Not enough time to debrief
Participants leaving with a
bad taste or negative
experience
• Lack of faculty buy-in or
untrained faculty doing the
debriefing
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Majority of negatives can be
controlled by the faculty.
Situation(al) Awareness
Shared mental model – all team members
are “on the same page”
1. what has happened already
2. what is happening now**
3. what is expected to occur
“Frames”
Each interaction is shaped by:
• Priorities (medical, nursing or personal)
• Knowledge and experience (or lack thereof!)
• Assumptions about how things will unfold
These are factors that influence the “frame” of
mind
• Teaching and effective communication are really
processes of “reframing” - changing the frame
of your colleague, your trainee, or yourself
Rudolph, 2007
Let’s practice framing.
AN ALTERNATE TITLE MAY BE:
Getting the monsters out of
your debriefing closet:
Strategies for improvement
Monster’s Inc.
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Watch simulation
Stop and talk about the monster
Debrief the monster (Next slide)
Then watch the movie debriefing
Debrief the debriefing
Debriefing
• positive: video-taped, immediate, possibly had good
questions
• Not so positive: started with a negative, kept the
student standing, questioned while student was
standing, condescending tone of voice, right in the sim
lab over the child/pt;
Monster’s Possible Frames
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He is stupid
He is lazy
He is distracted (personal - fight with wife)
He is fixated on being very scary
He is prioritizing his own escape route
He doesn’t know what he’s supposed to do
He thinks the open door adds an extra element of
“scary”
He might need backup from the monster world
What else?
Best Practices from the Literature
Debrieifing should take place away from simulator,
preferably another room; quiet (Johnson-Russell &
Bailey, 2010)
• Immediately after SCE completed
• Professional learning environment (lab coats or uniforms)
• Maintain confidentiality (HIPAA violation if disclosed)
• Safe environment where the facilitator was present for
SCE
• Faculty promotes value of activity (Roger’s Diffusion of
Innovation Theory—faculty buy-in)
• Video allows learners to evaluate what actually
happened—and not what they think happened (Fanning
& Gaba, 2007)
• Time of shared learning, rather than evaluation (JohnsonRussell & Bailey, 2010)
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Best Practices from the Literature
How long should debriefing last? IT ALL DEPENDS
▫ 2-4 times as long as scenario
▫ Longer for novice learners than experienced
▫ Longer for experienced learners as their scenarios are
more complex
▫ Until the learning objectives are met
(we do know the debriefing is the most valuable part,
logical it should be as long or longer than the scenario;
what if the group really gets it? What if the group totally
doesn’t get it? It always takes longer for students to do
stuff than you think) Don’t cut into debriefing.
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UWG strategies (Reflection sheet and Checklist) to speed up debriefing
UWG sim schedule
Methods Of Debriefing
• Rudolph: 3 Step (Reactions, Understanding [A-I],
Summary)
• Petranek: 4Es Events, emotions, empathy, explanations
• Plus/Delta (What went well? Better next time?)
• DASH method—Harvard (Debriefing Assessment for
Simulation in Healthcare) Excellent behaviorally-based tool
to assess the debriefer/debriefing. 7pt Likert scale with 6
key elements
• OPT Model of Clinical Reasoning (Outcome Present StateTest Model) (Kuiper, Heinrich, Matthias, Graham, BellKotwall, 2008)
• Written--followed by or preceded by verbal debriefing
• Journaling
• Survey Monkey link w/in 24 hours
Effective Techniques
Socratic, open-ended questions
– “Why” them to death.
– Talk to me about what prevented you from….
– Talk to me about what….
– “What were you thinking when ‘that’ happened?”
– What interventions were necessary that were not
performed?
– Situational awareness questions and anticipatory
questions
Make relationship to real world problems—application,
application, application.
Encourage learners to look at their behavior ---Reflection:
Reflection on action vs. Reflection in action even when
distracted
Tanner’s Clinical Judgment Model
Effective Techniques
• Explore how group functioned as a team
• Address questions to group, not individual
• Be nonjudgmental; empathize ---put yourself in the
student’s shoes, sometimes faculty take it personally
• Silence is not a problem! It’s thinking and processing
time for the student
• Rephrase, reflect, reword, echo, repeat—I heard you
say you were upset, can you explain that further, can
you tell me more about that (Communication
techniques)
• Student comments on teamwork, but not one-on-one
peer eval (positive peer action can be effective)
Effective Techniques
Advocacy-Inquiry
• Advocacy—provide the feedback to the learner
by describing the mismatch between
performance and the objectives or standard of
care
PAIRED WITH
• Inquiry—Genuine curiosity to understand the
learner’s thought or “frame” that drove their
actions or clinical decision making.
Examples Of Advocacy-Inquiry
Dirty question: Why didn’t you call for help earlier?
A-I: I noticed that you did not call for help until the pt
coded and I was concerned that help earlier could have
possibly prevented the code. What are your thoughts?
No “guess what I am thinking” game.
If we do not understand the thinking behind actions how
can we change them?
Practice A-I
• Why did you let the pt desaturate?
• Why didn’t you give the NTG earlier?
• Why didn’t you call the physician earlier?
Recommendations
• Move away from plus/delta
• Recommend Common 4-step Format for
Debriefing to Fulfill the Facilitator Role
1. Introduction
2. Personal Reactions
3. Discussion of Events (Understanding)
4. Summary
I. Introduction
Communicate faculty expectations
– Prepares learners to actively analyze and evaluate self
and simulation activities
– Honest communication
How debriefing will proceed
Describe faculty role
– Facilitator vs evaluator or instructor
Discuss confidentiality
– What goes on in the sim lab stays in the sim lab
(HIPAA)
Safe environment for expression of feelings and asking
questions
– Mistakes are part of the learning process, no
punishment, not look bad in front of peers, criticismfree
Consequences if the scenario is shared
– other students robbed of the learning experience
II. Personal Reactions
Recognize and release emotions built up during
simulation (Fritzsche, Leonard, Boscia, & Anderson,
2004)
Learners with opportunity to explore and deal with
feelings experienced during simulation are better
prepared to deal with them in real clinical situations
(Henneman & Cunningham, 2005)
• Let them express their personal reactions.
• Begin with open-ended questions
• Reflective responses to student’s statements
• Ensure that all have opportunity to respond
(Sally, can you tell me something that Tim did well?)
III. Discussion of Events
• Review objectives of SCE
• During discussion, encourage participants to continually analyze
the events in depth and their feelings, thoughts, and reactions
to them
▫ Students learn and remember more when they participate
actively and make their own analysis (Duvall & Wicklund,
1972)
• Answer questions, clarify student thinking, emphasize teaching
points (Fritzsche, Leonard, Boscia, & Anderson, 2004; Jeffries,
2005)
• Guide students to the answers; use resources
• Reflective Learning (Mort & Donahue, 2004)
• Self-assessment (Silent or spoken)
Why you acted as they did, to correct it, to do differently?
Individually, what do you need to work on?
• Encourage feedback from peers (Henneman & Cunningham,
2005)
• Focus on performance, not performer
III. Discussion of Events
Ask Questions like:
▫ Tell me what happened?
▫ What did you do as a team or individually when that
happened?
▫ What would you do differently next time, individually,
as a team?
▫ What additional information, knowledge, skills, etc. do
you think were needed in the situation?
• Clarify Information
▫ Students may manipulate the data in such a way that
they distort it and make it fit into their previous learning
▫ Through debriefing process, faculty can ensure that
new learning is processed correctly (Chiodo & Flaim,
1993)
▫ Connect theory to practice
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III. Discussion of Events
• Question errors in judgment
▫ Complacency with abnormal VS
▫ Vigilance errors like failure to attend to changing status
• Ask about communication with patient, family members, team members
• Review charting
• Review prioritization of care
• Review published/standardized guidelines (Owen & Follows, 2006)
• Acknowledge the unreality
▫ “No, the simulator is not a real person, but . . .”
▫ “You didn’t have a chart? Have you had a situation where you haven’t
had everything you needed? What did you do in that case?”
▫ Will often try to blame the simulator if things go wrong
• Link what has been learned in simulated setting to real world (Chiodo &
Flaim, 1993; Fritzsche, Leonard, Boscia, & Anderson, 2004; Peter &
Vissers, 2004)
• How didactic and theory apply to patients with this condition
IV. Summary
Goal is to assist students to look at overall
experience: what they did, what they learned,
what they want to work on
Faculty can summarize or ask open-ended
questions of the students to summarize:
▫ What did you learn that was new?
▫ What do you need to work on individually? As a
group?
Example: UWG blue sheet
IV. Summary
End on a positive note (food works well)
• “In summary, these are the things you
identified as going well. . .”
• “These are the things you told me you need to
work on. . .”
• “The take home points include. . .”
• “I saw improvement in these areas. . .”
Thank the students for participating in the SCE
and debriefing
Complete written work or evaluations
• Debrief this performance
• Goals are to provide safe, effective nursing care and
keep the patient alive.
http://www.youtube.com/watch?v=PQHPU
kEViKk
Inhibiting the Debriefing
• Instructor teaches content
• Asks closed-ended questions
• Answers questions before learner has
chance to process
• Judgmental and critical, belittling
• Major focus is on errors
Other Considerations
Simulated patient death or perceived death
▫ Debriefing is vital: support, reassurance, guidance
knowledge (Allchin 2006; Walsh & guidance, Allchin,
Hogan, 2003; Thiagarajan, 1992)
Disruptive or dominant learners
Critical of peers
Disengaged learners
Faculty Debriefing of the Debriefing
It’s important to improve our own performance.
• What worked, what didn’t?
• Any changes needed?
• What was learned about the students in general and
about the curriculum?
• Review student evaluations
• Adjust as needed
• FACULTY SHOULD BE DEBRIEFED AT THE END OF THE
SCENARIO OR SEMESTER. Review student evaluations of
each scenario, sim program, faculty…survey monkey.
• Video tape debriefing to debrief the debriefer.
Learning Objectives
At the end of this session the participant
will be able to:
1. Identify the goals of debriefing.
2. Discuss the elements of debriefing that
improve outcomes.
3. Identify various approaches to
debriefing.
4. Discuss the process of debriefing.
Debriefing Today’s Session
• What did you learn today that was new?
• What do you need to work on individually? As a group?
• What best practice will you incorporate with your next
debriefing?
• Thank you for coming and sharing
bishoy@westga.edu
References
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Allchin, L. (2006). Caring for the dying: Nursing student perspectives. Journal of Hospice and
Palliative Nursing, 8(2), 112-117.
Chiodo, J. L., & Flaim, M. L. (1993). The link between computer simulations and social studies
learning: Debriefing. Social Studies, 84(3), 119-121.
Duvall, S., & Wicklund, R. A. (1972). A theory of objective self awareness. New York, NY: Academic
Press.
Fanning, R. M., & Gaba, D. M. ( 2007). The role
Jeffries, P. R. (2005). A framework for designing, implementing, and evaluating simulations used as
teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96-103.
Mort, T. C., & Donahue, S. P. (2004). Debriefing: The basics. In W. F. Dunn (Ed.), Simulators in
critical care and beyond (pp. 76-83). Des Plaines, IL: Society of Critical Care Medicine.
Owen, H., & Follows. V. (2006). Really good stuff: GREAT simulation debriefing. Medical Education,
40(5), 488-489.
Peters V A M & Vissers G A N (2004) A of debriefing in simulation based learning. Simulation in
Healthcare, 2(2), 115-125.
Fritzsche, D. J., Leonard, N. H., Boscia, M. W., & Anderson, P. H. (2004). Simulation debriefing
procedures. Developments in Business Simulation and Experiential Learning, 31, 337-338.
Graling, P., & Rusynko, B. (2004). Kicking it up a notch- successful teaching techniques. AORN
Journal, 80(3), 459-475.
Henneman, E. A., & Cunningham, H. (2005). Using clinical simulation to teach patient safety in an
acute/critical care nursing course. Nurse Educator, 30(4), 172-177.
Hravnak, M., Tuite, P., & Baldisseri, M. (2005). Expanding acute care nurse practitioner and
clinical nurse specialist education: Invasive procedure training and human simulation in critical
care. AACN Clinical Issues, 16(1), 89-104.
Peters, V. A. M., Vissers, G. A. N. 2004). simple classification model for debriefing simulation
games. Simulation and Gaming, 35(1), 70-84.
Rudolph, J., Simon, R., Rivard, P., Dufresne, R. & Raemer, D. (2006). There’s no such thing as
“nonjudgmental” debriefing: A theory and method for debriefing with good judgment. Simulation in
Healthcare, 1(1), 49-55.
Rudolph, J., Simon, R., Rivard, P., Dufresne, R. & Raemer, D. (2007). Debriefing with good
judgment: Combining rigourous feedback with genuine inquiry. Anesthesiology Clinics, 25, 361376.
Thiagarajan, S. (1992). Using games for debriefing. Simulation & Gaming, 23(2), 161-173.
Walsh, S. M., & Hogan, N. S. (2003). Nursing students’ commitment of “Presence” with the dying
patient and the family. Nursing Education Perspectives, 24(2), 86-90.