Simulation Debriefing

Healthcare Simulation Debriefing is a period of time following an experiential learning activity during which learners/teams reflect, review and discuss the activity with the goal of improving individual and team clinical skills and judgement. Here we take a deeper look at the simulation debriefing process and provide a handful of examples from the many debriefing models available from clinical educators around the world.

In the past, many healthcare disciplines relied on the apprenticeship model which relied on learners encountering enough situations to ensure that they became competent. More recently, healthcare simulation has become extensively used as it provides scheduled, valuable learning experiences where learners not only put their knowledge into practice, but also practice decision making and communication skills.

Clinical Simulation scenarios range in complexity and/or skill level. For example, medical simulation maybe used for undergraduate nursing students to practice medication administration or for obstetrical residents practicing caring for a woman with postpartum hemorrhage. Following each scenario, a debriefing is conducted by one or more people such as a simulation facilitator who are considered content experts about the scenario subject matter. These content experts should also be skilled in debriefing. Many would argue that debriefing is the most important component of a simulation experience.


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Debriefing

The origins of debriefing began in the military where individuals returning from a mission would give a report about the mission. The information provided could then be used to strategize for future missions or to reduce psychological damage from a traumatic event. In healthcare simulation, debriefing is used to foster discussions in a non-threatening environment, capture and leverage “golden or ah ha” moments, seek similar real-world experiences and help apply the experience to real-world practice. Debriefing is considered a reflective practice since it is a method used to scrutinize a learner’s own assumptions and professional work practices (Kolb 1984). People make sense of external stimuli though internal frames of reference. During debriefing, learners and educators identify these frames of reference (aka mental model) and the learner decides if the frame of reference is appropriate or changes should be made. Ultimately, this may lead to a future change in behavior which in turn, leads to an improvement in clinical practice.

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Several factors affective the nature of a simulation in healthcare debriefing. These factors include the objectives of the simulation, complexity of the scenario, experience level of the learners, familiarity of learners with the sim environment, time available for the session, audiovisual recording systems, and individual personalities of participants. Creating a safe learning space is a critical consideration since participating in simulations can have a significant emotional impact on learners, which should begin with the orientation and again in the prebriefing. Opening questions often include basic what or how questions. Many questions are open ended and should always be non-judgmental. Participants should be encouraged and made to feel that their contributions are valued. Faculty often reflect back learner statements to reiterate points or to open up a discussion. Debriefing should occur immediately following simulation. Note, debriefing is all about the learners who should do most of the talking and not about the educator. Simulation and debriefing are used extensively to improve team communication, dynamics and efficiency.


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Medical Simulation Debriefing Tool Samples

  • Bubble Briefs (Hall, A and Turner, J): The “Bubble Briefs” consists of a framework of non-technical skills and human factors questions that may be pertinent during the debrief. We use eight cards that provide human factor topics to those observing the scenario. They include topics such as leadership, teamwork and resource allocation, communication, situational awareness, and handover. Each card has several open questions to give recommendations on what to observe during the simulation and how to ask questions and analyse behavior during a debrief. Before a Simulation session, the participants are shown the Bubble Briefs and had an explanation of human factors and non-technical skills. Prior to a given simulation scenario, the Bubble Briefs are chosen by faculty depending on the learning objectives of the scenario.
    • Framework of non-technical skills and human factors.
    • Leadership, teamwork and resource allocation, communication, situational awareness, and handover.
  • SHARP – Imperial College London: SHARP contains the absolute basic principles of what to cover when conducting a debriefing. SHARP is an acronym that comprises five ‘prompts’ to guide trainers and trainees in providing/receiving a structured debrief. SHARP stands for Set learning objectives, How did it go, Address concerns, Review learning points, Plan ahead. It is a practical tool which can be used when there is not enough time to carry out a detailed debriefing using all the comprehensive information provided in the Objective Structured Assessment of Debriefing (OSAD) tool
    • Five step feedback and debriefing tool.
    • Before cases.
      • Set learning objectives.
      • What would you like to get out of this case?
    • After case
      • How did it go?
      • What went well? Why?
    • Address concerns
      • What did not go so well? Why?
      • Review learning points
      • Were your learning objectives met for this case?
      • What did you learn about your clinical/technical skills?
      • What did you learn about your teamwork skills?
    • Plan ahead
      • What actions can you take to improve your future practice
  • Debrief as a Learning Conversation (Denning, K): The learning conversation was developed initially by two educators for the Advanced Life Support group: Dr Davis and Dr Denning six years ago as a mechanism for providing effective feedback to students on resuscitation courses and evidence to support its introduction initially was published in 2016 (Chapter 8. Pocket guide to teaching for Clinical instructors). Adults are by nature independent learners and generally choose to learn what they feel is relevant to them, they construct their learning on what they read, see and do and the degree of retention depends on their perception of what is useful. Such self-organized learning creates meaning from experience (actual and simulated) Knowles MS et al 2005 and feedback is fundamental to reflective practice and the supervision of learners. There has been a paradigm shift in recent years such that feedback is thought to be as important as simulation practice itself in terms of learning, it not only encourages reflection but offers processes to improve.(Issenberg et al 2005).
    • Make opening gambit (phrases)
    • Jointly explore any issues that emerge
    • Include impressions/suggestions from rest of group
    • Share your thoughts using advocacy with inquiry
    • Check whether anyone has any other issues that they want to discuss
    • Summarize
  • Gather, Analyze, Summarize Method (GAS): Debriefing is recognized as a best practice in simulation education but is only one of several methods of providing participant feedback. The purpose of a debriefing is to provide students with the opportunity for review of their simulation experience through facilitated dialogue which leads to reflection, enhanced learning, and change in practice. In this chapter, the authors describe the development and use of a structured method for debriefing individuals and teams of providers. Developed in collaboration with the American Heart Association, the “structured and supported method” includes three phases with associated goals, objectives, and time frames. Many simulation educators are busy, practicing professionals. Because of this, the primary development goal was to build a streamlined debriefing method which was both easy to learn and scalable. It was also important that the method drew on available literature and was validated by use at the Winter Institute for Simulation Education and Research (WISER). Another aspect when considering the method includes use of the gather, analyze, and summarize (GAS) debriefing tool. This tool allows even novice debriefers to rapidly gain skill in debriefing while remaining comfortable with the process. Ability to maintain a student-centric, safe environment where gaps in knowledge, skill, or performance are identified and addressed is central to the method.
    • Gather data by actively listening to participants to understand their perspective
    • Analyze
      • Facilitate student reflection and analysis of their actions.
      • Identify positive aspects of team or individual behaviors that require change.
    • Summarize
      • Facilitate identification and review of lessons learned.
  • Debriefing with Good Judgement (Rudolph et al, 2007): Drawing on theory and empirical findings from a 35-year research program in the behavioral sciences on how to improve professional effectiveness through reflective practice, we develop a model of “debriefing with good judgment.” The model specifies a rigorous reflection process that helps trainees surface and resolve pressing clinical and behavioral dilemmas raised by the simulation. Based on the authors’ own experience using this approach in approximately 2000 debriefings, it was found that the “debriefing with good judgment” approach often sparks self-reflection and behavior change in trainees.
    • The model states that there is no such thing as “nonjudgmental” debriefing
    • Debriefing should be done with “good judgment”.
    • The model utilizes an advocacy inquiry approach:
      • Notice a relevant result – something that happened in the simulation.
      • Observe what actions seemed to lead to the result.
      • Use advocacy inquiry to discover the frames that produced the results.

Debriefing is not about the specific tool used or the debriefer/content expert but rather about the learners. Because debriefing provides an opportunity for learners to reflect and change future behaviors, it plays an important role in healthcare education and ultimately, in the improvement of patient care and the prevention of errors. Subscribe to our free newsletter for all the latest simulation debriefing news!

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