October 9, 2019By Dr. Kim Baily

Downloadable DASH Debriefing Tools From Center for Medical Simulation

Although the glitzy part of healthcare simulation often focuses on high fidelity manikins, most learning occurs during the debriefing. Debriefing clinical simulation experiences is increasingly understood as a crucial step in clarifying and consolidating insights and lessons from simulations. The Debriefing Assessment for Simulation in Healthcare (DASH) is designed to assist in evaluating and developing debriefing skills. Today Dr. Kim Baily PhD, MSN, RN, CNE, examines the theory, practice, and tools of DASH as made available from the Center for Medical Simulation — including a link to their free DASH debriefing tools below!

Debriefing is a conversation among two or more people to review a simulated event or activity in which participants explore, analyze and synthesize their actions and thought processes, emotional states and other information to improve performance in real situations. High participant engagement is a hallmark of strong debriefings because it leads to deeper levels of learning and increases the likelihood of transfer to the clinical setting. The DASH evaluates the strategies and techniques used to conduct debriefings by examining concrete behaviors. It is based on evidence and theory about how people learn and change in experiential contexts. The DASH is designed to allow assessment of debriefings from a variety of disciplines and courses, varying numbers of participants, a wide range of educational objectives, and various physical and time constraints.

During the debriefing stage, learners have an opportunity to reflect on their actions and consider what frames of reference they used to drive either their interventions or lack of interventions during a simulation scenario. The debriefer (facilitator/instructor) uses a specialized set of skills to assist the learner in identifying what went well, what behaviors need to be changed (performance gaps) and most importantly what frames of reference the learners used to make their clinical decisions. Only when learners identify the frames of reference, can they make internal changes to alter future behavior.

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Just as the medical simulation participants are learners, so too are novice debriefers. Debriefers need knowledge and experience in order to debrief successfully and to create a safe learning space where learners are not intimidated but are challenged to consider their actions. The simulation process may necessitate identifying errors or areas of practice that do not meet accepted standards. Assigning clinical education staff to simulation debriefing without adequate preparation, practice and guidance can lead to simulation experiences where learners are frustrated and are reluctant to participate in future simulation sessions.

Debriefing Assessment for Simulation in Healthcare (DASH).

The Center for Medical Simulation (CMS) at Harvard created a generalized assessment tool to facilitate assessment of debriefings for a variety of disciplines and courses. The assessment is based on concrete behaviors and how people learn and change during experiential learning. Scoring Sheets have been developed for students participating in simulation, instructors (self-evaluation) and debriefing raters who are experienced in both debriefing and DASH assessment.

The score sheets have the same elements but are written appropriately for each group of participants i.e. student, instructor and rater. Each score sheet is further divided into short and long forms which can be used in formative and summative assessments. The score sheet should be used with the rater handbook which provides details about the assessment. The handbook provides effective and ineffective debriefer behaviors.

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Note, all these assessment sheets and handbooks are available for free on the CMS website and are available in English, French, German, Japanese, Spanish. The original work for these assessment sheets were published between 2010 and 2012 by Simon R, Raemer DB, Rudolph JW. however, the CMS has updated the sheets on a regular basis. Everything needed to start using these tools is available on the CMS website linked below.

The DASH scores showed evidence of reliability and preliminary evidence of validity in a study entitled Debriefing Assessment for Simulation in Healthcare: Development and Psychometric Properties (Brett-Fleegler, Marisa MD; Rudolph, Jenny PhD; Eppich, Walter MD, MEd; Monuteaux, Michael ScD; Fleegler, Eric MD, MPH; Cheng, Adam MD; Simon, Robert EdD. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: 2012, Vol 7, pp 288-294. doi: 10.1097/SIH.0b013e3182620228).

DASH Identified Six Key Characteristics of Successful Debriefing:

  1. Establishes an engaging learning environment (prior to simulation):
    1. Provides a safe learning environment
    2. Describes benefits of simulation
    3. Reviews course objectives, environment, roles and expectations (fiction contract)
    4. Conveys a commitment to respecting learners and understanding their perspective.
    5. Provides for physical care and comfort.
  2. Maintains an engaging learning environment.
    1. Conveys respect for the learners
    2. Clarifies debriefing objectives, roles and expectations
    3. Treats scenarios as cases thereby establishing realism
  3. Structures debriefing in an organized way.
    1. Beginning: Allows learners to express emotional reactions, helps identify participants concerns and therefore helps guide objectives to be covered.
    2. Middle: Analysis phase which helps learners move towards accomplishing course objectives and involve participants in discussion regarding why events occurred.
    3. Ending: Summary phase where important points are reviewed and participants summarize what they have learned.
  4. Provokes engaging discussions.
    1. Observable actions and outcomes are used as a basis for discussion.
    2. Debriefers own reasoning and judgments shared.
    3. Use nonverbal cues.
    4. Use video and replay if available.
    5. Recognizes and manages the upset participant.
    6. Discuss practical considerations and applications.
  5. Identifies and explores performance gaps.
    1. Provides feedback on performance describing performance gaps.
    2. Explores the basis for performance gap and why.
  6. Helps trainees achieve or sustain good future performance.
    1. Elicit techniques from participants to perform more effectively.
    2. Debriefer must demonstrate knowledge of the subject
    3. Must meet the objectives of the simulated case.

Successful debriefing is often challenging since it involves identification of performance gaps and yet debriefers have to strike a balance between identifying the gaps and being overly critical of errors.

The DASH Rating Scale (Rating Score & Descriptor):

7) Extremely Effective/Outstanding

6) Consistently Effective/Very Good

5) Mostly Effective/Good

4) Somewhat Effective/Average

3)  Mostly Ineffective/Poor

2) Consistently Ineffective/Very Poor

1) Extremely Ineffective/Detrimental

Healthcare practitioners may feel vulnerable and anxious while being observed during simulations. Debriefers/Instructors need to ensure that learners who participate in simulation feel valued and respected. Adequate instructor preparation and assessment is key to ensure that debriefers have the knowledge and skills necessary to successfully debrief.

As the role of clinical simulation increases both in the clinical and academic settings, the need for standardization also increases. This is particularly true when simulation is being used to replace face to face patient care. More and more accreditation standards now include criteria specifically related to simulation. Therefore it follows that both the debriefing experience and the educators that conduct debriefing should be assessed. The DASH method provides useful tools for the assessment of instructors by students, faculty and raters.

Download the DASH Debriefing Assessment Tools Now!

Today’s article was guest authored by Kim Baily PhD, MSN, RN, CNE, previous Simulation Coordinator for Los Angeles Harbor College and Director of Nursing for El Camino College. Over the past 16 years Kim has developed and implemented several college simulation programs and previously chaired the Southern California Simulation Collaborative.

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