Hello, and welcome to The Basics of Debriefing in Simulation. This is the first session in the debriefing module. My name is Dr. Kristina Thomas Dreifuerst, and I'm going to be guiding you through the three sessions of this module. I'm an Assistant Professor of Nursing at Marquette University in Milwaukee, Wisconsin, in the United States. I have been a recognized expert in debriefing for more than a decade. During those years, we've made great strides in our understanding of the role that debriefing plays in simulation learning, and there is increasing evidence of best practices. During these three sessions, we will touch on the history of debriefing, communication strategies, debriefing methods, and evidence-based practices. All of the sessions will help you to become a better debriefer in healthcare simulation. So, let's get started. There are four objectives for this first presentation in the session. The first objective is to be able to identify key components of debriefing that evolved through history. The second objective is to be able to compare and contrast feedback and debriefing. The third objective is to be able to integrate evidence-based practices and the INACSL Standards of Best Practice: Debriefing into your debriefing. And finally, the fourth objective is to be able to discuss the importance of debriefing for participant learning in the simulation experience. Although there are many definitions of healthcare simulation debriefing in the literature, for this module, we are going to use this one that I really like. It comes from the glossary of the INACSL Standards of Best Practice for Simulation. Simulation Debriefing is a reflective process immediately following simulation that is led by a trained facilitator using an evidence-based debriefing method. Participant's reflective thinking is encouraged and feedback is provided regarding the participant's performance in various aspects of the simulation. Participants are encouraged to explore emotions and question, reflect, and provide feedback to one another. The purpose of debriefing is to move toward assimilation and accommodation to transfer learning to future clinical situations. So, let’s think for a moment about what this means and how we will apply it into our simulation practice. How do we help learners think reflectively? Most often, this is done by the debriefer asking open-ended Socratic questions to get the learners engaged in the discussion. These probing questions are asked in a non-threatening way to help learners think through their actions and decisions during the stimulation, and talk about their experience in debriefing. Feedback and debriefing. You'll recall that the definition of stimulation debriefing that we are using included the phrase, feedback, is provided, regarding the participant's performance in various aspects of the simulation. In fact, depending on the learning objectives of the simulation, feedback can be predominant, and in the forefront, like the box on the left. Particularly, if the simulation is heavily focused on task training or skill development. In that case, then much of the debriefing time will be spent providing feedback. This is often given using a plus delta format where what went right is discussed, what went wrong is discussed, and what should be done differently next time is discussed. This can be formative feedback, which is provided as information to improve performance, but it can also be summative feedback, when the simulation is done to test the learner's abilities at the end of a term, rotation, course, semester, or a natural break in the curriculum. Summative feedback can be associated with a grade or evaluation, and can be considered a high stakes performance assessment. Similarly, cumulative feedback is associated with the end of a program, or at the time of licensure or credentialing, and is usually high stakes. Debriefing, on the other hand, includes some feedback, but there's also an emphasis on recalling the events of the simulation and then discussing the thinking and the decision-making that occurred to understand the events of the experience from the perspective of the participant in order to ensure that safe and quality care is provided. Therefore, reflection is in the forefront, like at the box on the right. Finally, some discussion of the emotions of that participant can be a part of debriefing. Strong emotions, however, can distract the participants from focusing on the learning occurring during the debriefing. Therefore, acknowledging and providing an opportunity to process emotions can facilitate debriefing learning outcomes. In fact, different methods of debriefing provide different options for handling participant emotions. Debriefing, as a form of communication and sense-making, has been used throughout history. The military has a rich history of the use of the feedback aspect of debriefing,, particularly during times of conflict or war. The leaders, or the generals, would be in one location while the conflict occurred at another. And there would be designees who would travel from the command center to the front and deliver the plan of attack, and then they would travel back and report on what went right and what did not. There was often a psychological trauma associated with the events at the war front, so these designees could be so traumatized that they could not verbalize what had occurred, or they needed religious leaders and/or philosophers and educators to help them process the events, so they could continue in their role. Over time, this has evolved into a structured military debrief that focuses on feedback. The airline industry has also used debriefing. This shouldn't be a surprise since many pilots come from a military background, and flying a plane is very procedure orientated. They've incorporated the use of a brief, or a team huddle, before the flight and a recap, or debrief, once the plane has landed and all passengers have deplaned. Most of these are very short and focus on a feedback model, where the crew discusses the standard operating procedures, what went right, what went wrong, and what should be done differently next time. Medicine, which is also highly procedurally based and process oriented, has adopted this model of brief and debrief. Many simulations within medicine focus on task training or skill development and demonstration. As such, the emphasis on feedback works well and can be accomplished in short amounts of time. Within the discipline of nursing, however, most simulations are less procedure and process focused with more emphasis on having students apply knowledge, clinical reasoning, decision-making, prioritization, and communication, in addition to tasks or skills during the care of the patient in the scenario. For this reason, debriefing in nursing is often less focused on feedback and more focused on uncovering the thinking that underpins the nursing action of the participant. Although plus delta models are also commonly used, reflection is a dominant construct in nursing debriefing. Now, this is a busy, but very important slide. The International Nursing Association for Clinical Simulation and Learning, standards of best practice include an entire standard for debriefing. The most current version from 2016 states that all simulation-based experiences include a planned debriefing session aimed at improving future performance. And when you dig deeper, the criteria say that first, debriefing must be facilitated by a person competent in the process of debriefing. It goes on to say that debriefing must be conducted in an environment that is conducive to learning and supports confidentiality, trust, open communication, self-analysis, feedback, and reflection. And debriefing must be facilitated by a person or persons who can devote enough concentrated attention during the simulation. Debriefing must also be based on a theoretical framework for debriefing that is structured in a purposeful way, and be congruent with the objectives and outcomes of the simulation-based experience. So, what does all of this really mean? Remember, the standards of best practice come from the evidence that is available at the time the standards are written. They are dynamic, or ever-evolving documents, that will continue to change as the evidence changes. The essence of what the standards says is that first, debriefers need to be competent in the process of debriefing. Today, however, competence has not yet been defined, so the term remains a bit nebulous. The way it's being enacted is that some formal training in debriefing is necessary to meet this criterion. Once again, however, the definition of what constitutes formal training has not been established. To meet the second aspect of the criteria, debriefing must occur away from the clinical environment and the patient being cared for in an area that is private, so that everyone can speak freely. A critical aspect of debriefing is a component of pre-briefing called setting the safe container. This essentially means that each time a simulation occurs, the facilitator verbally contracts with the learners to establish that what is going to occur during debriefing will be kept confidential, in order to facilitate trust and open communication, as well as self-analysis and feedback. To do this, it is important that debriefing occurs in a location where it cannot be overheard. The third criteria of the standard is perhaps the most challenging. The evidence is clear that debriefers need to focus on what the learners are doing during the simulation, in order to be good facilitators of reflection and feedback. This means that the debriefer cannot also run the mannequin fidelity and the computer, or be the voice of the patient or another provider during the simulation. The role of the debriefer is to immerse themselves solely in observing the simulation and preparing for debriefing. When there are limited resources or personnel for simulation, this can be very challenging. The fourth criterion states that debriefing should be theoretically derived and evidence-based. Several, but not all, established methods of debriefing that are commonly used in healthcare simulation today meet this criterion. Finally, debriefing should be well aligned with the objectives and outcomes of the simulation. So, why is debriefing so important for learning? The evidence points to the importance of reflection for assimilation and accommodation. During assimilation, the participants recognizes cues and information that are familiar and even anticipated. Therefore, they call upon reasoning, decision-making, and even actions that they have used before, and are now applying into this different, new clinical situation. Accommodation is necessary when the cues and information reveals something that is unfamiliar. Therefore, the reasoning, decision-making, and actions that participants have used before need to be adjusted or changed to fit this different and unique clinical situation. Through debriefing, the facilitator can guide learners to reflect and dialog on the aspects of the experience that were assimilation, and those that were accommodation, weaving feedback into the discussion, as thinking and actions are discussed. All of this rich discussion prepares the learner for the next time they encounter this type of clinical situation or patient. Here are some final thoughts. The literature regarding debriefing and healthcare simulation is rapidly growing, and our understanding of the importance of this aspect of simulation experience is also changing. Many times, the focus of the time allotted for the simulation experience has been on patient care. However, the research is demonstrating that the debriefing is critically important and should have sufficient time allotted to ensure that meaningful learning occurs.
