Debriefing

Sandra J. Feaster, RN, MS,MBA

Program Director

Center for Immersive and Simulation-based Learning (CISL)

Stanford University, CA

http://cisl.stanford.edu

DEBRIEFING IS THE “HEART AND SOUL” OF THE SIMULATED EXPERIENCE

- RALL, MANSER, & HOWARD, 2000

Objectives

Identify the goals of debriefing Discuss the elements of debriefing Identify various approaches to debriefing Discuss the process of debriefing Formulate questions that assist students in

self-reflection

Defining Debriefing Merrian-Webster (1945)

1 : to interrogate (as a pilot) usually upon return (as from a mission) in order to obtain useful information

2 : to carefully review upon completion <debrief the flight>

Wikipedia, the free encyclopedia A debriefing or psychological debriefing is a one-time, semi-

structured conversation with an individual who has just experienced a stressful or traumatic event. In most cases, the purpose of debriefing is to reduce any possibility of psychological harm by informing people about their experience or allowing them to talk about it.

Debriefing starts with the “Prebriefing”

Prebriefing Describe the purpose of

the simulation The learning objectives How the process of

debriefing will occur The learner will in turn:

Know the expectations of the simulation

Know the ground rules for their experience

The instructor should be prepared

To understand that learners will come with their own experiences and frames

The Origins of Debriefing

Military - the account individuals gave on returning from

a mission Information analyzed and used to strategize for

future missions/exercises (educational & operational)

An aided process to reduce the psychological damage of a traumatic event

The Origins of Debriefing Critical Incident Debriefing

Used to mitigate stress among emergency first responder

CISD (Critical Incident Stress Debriefing)* Psychological debriefing (modified CISD)**

Facilitator-led approach to enable participants to review the facts, thoughts, impressions and reactions after a critical incident

Aim - reduce stress and accelerate recovery after a traumatic event

Issue - concern that a single session approach may be inadequate is certain situations or with certain people

* Mitchell, JT, Everly GS: Critical incident stress debriefing: An operations manual for the prevention of traumatic stress among emergency services and disaster workers (1993)

**Dyregrov A : Caring afor heapers in diseaster situations: Psychological debriefing: Disaster Manage 1989

The Origins of Debriefing

Experimental Psychology Participants who have been deceived as a part

of a psychology study are informed of the true nature of the experiment

Purpose is to allow dehoaxing to occur and reverse the negative effects of the experience

Educating Adult Learners via Simulation

Much of learning from simulation is dependent on the impact of the experience. The event/experience needs to be relevant to

make an impact. The learner must be moved by the

event/experience to make an impact.

EXAMPLE: Simulation with airway obstruction

Learning and Debriefing in Simulation

I hear and I forgetI see and I rememberI do and I understand

Confucius I trust and discuss

Fanning, Gaba*

* Fanning, RM, Gaba, DM, The Role of Debriefing in Situation-based Learning, Simulation in Healthcare, 2007

Debriefing Principles

Foster Discussion in a non-threatening fashion

Capture and leverage “golden or ah-ha” moments

Seek similar real-world experiences Help apply the experience to real-world

practice

Emotional Learning

Emotional state can affect retention and activation

How has the learner “framed” the experience

Reflective Practice

Method used to scrutinize one’s own taken-for granted assumptions and professional work practices.

The theory of reflective practice draws on cognitive science, social psychology, and anthropology.

People make sense of external stimuli through internal cognitive “frames” (or frame of reference, mental models, etc), internal images or external reality.

Rudolph, JW, Simon, R, Dufresne, RL, Raemer, DB. There’s No Such Thing as “Nonjudgmental” Debriefing: A Theory and Method for Debriefing with Good Judgment. Simulation in Healthcare, 2006

Frames are invisible to the instructor

FRAME ACTIONS RESULTS

Debriefing leads to new frames

Debriefing changes later actions

Rudolph, Simon, Dufresne & Raemer

Factors to consider in debriefing

Objective of the exercise Complexity of the scenario Experience level of the learners Familiarity of learners with the environment Time available for the session Role of simulation in curriculum Individual personalities and relationships

Factors to consider from the facilitators point of view

How many facilitators Has a plan been worked out in advance for

how you will facilitate What are the personalities of the faciltators?

Talkative, condescending, passive

Where should the facilitator(s) sit?

Practical Aspects of Debriefing

Setting - Physical Comfortable and private Think about seating style In-situ simulations

Setting – Emotional Prebrief – set the expectations

Confidentiality, role of the facilitator, role of the participant

Practical Aspects - Tips

Questioning Open ended, non-judgemental Begin questions with what, how, or why to

encourage deeper discussion

Follow-up on participant comments Make the participant feel their contribution is

important

Consider the emotional impact of the exercise

Practical Aspects - Tips

Include ALL participants Bring the quiet, withdrawn participant into the

discussion (they have thoughts about what is happening, but may have trouble sharing)

Reflect questions back to the participants Use silence appropriately (10 seconds is NOT

too long) Be observant to the body language of the group

or individual Understand group dynamics

Tips

Pros – Cons – Alternatives Plus (+) Delta

+ Delta

Example of good behaviors/actions

Behaviors/actions that would change or improve in the future

Easier Task or behaviors Behaviors or actions that were difficult

Things to Avoid

Too much instructor talking Trap of “telling” to teach Avoid “personal” evaluation before the discussion

ends

Too much medical/technical Too judgementa/condescending

Avoid interruptions Avoid “guess what I am thinking”

Have an agenda, use cognitive aids……. be flexible

HELPFUL QUESTIONS

Generic Repeating what the participant said to help

reiterate a point, or open a discussion Relate the event to real life If participants are apathetic, address questions

to them by name or go around the room in sequence

Consider starting the debriefing by calling on someone other than the primary participant

HELPFUL QUESTIONS

Generic statements What were the pros, cons, or alternatives to an

action If this were to happen in real life, what might

you do in the future Did you find the scenario challenging

HELPFUL QUESTIONS

Opening lines How do you feel that went What were your first impressions when you

arrived on scene Did you get an adequate handover Who/what where are other sources of

information about the patient/scenario Who was the leader Did you ask for help

HELPFUL QUESTIONS

Questions regarding task overload Were you and others in control of the situation What needed to be done How many people would this have required Ask the other participants how they felt – was

the person or scenario overloaded

HELPFUL QUESTIONS

Fixation Errors What did you think was happening Has anything like this happened in real life What made it difficult to think of other options

or possibilities at the time

HELPFUL QUESTIONS

Wrap up How did you hand over the scenario What were the take home messages of the

scenario (+ delta or pro, cons, alternatives can help here)

Review the aim of the simulation and how this can help in real life practice

Give the participants the opportunity to discuss/recontact you if there are further questions

In Summary: Elements of a Good Debriefing

Opened ended questions Positive reinforcement (but not false

positive) Use of cognitive aids Good use of AV capabiity

In Summary: Elements of a Poor Debriefing

Closed questions Criticism Focus on errors Focus on technical points Ignoring team work and communication Focusing too much on the AV or AV

problems

Closing Thoughts

Many of our peers feel that debriefing is the most important part of simulation training

Many also feel that poor debriefing can harm the trainee

Most feel a thorough prebriefing is essential

Confidentiality and a non-threatening atmosphere is important

Thank You! sfeaster@stanford.eduhttp://cisl.stanford.edu