Introduction

The learning that takes place in medical simulation settings is mainly experiential. Participants experience a novel situation in a simulated scenario and subsequently reflect on it, deepening their understanding of the relevant aspects of healthcare and (it is to be hoped) modifying their future behavior in the real world. One important factor affecting this post-experience reflection is the associated debriefing and analysis quality. Debriefing is reviewing critical actions that unfold during a simulation scenario.[1] The process of debriefing and its timing can take on many forms and techniques; regardless, the process should be learner-focused. The process of debriefing and feedback are sometimes used interchangeably; however, they are distinguishable. Debriefing is conversational, bidirectional, interactive, and reflective, while feedback is unidirectional and informational, providing a learner with crucial information about aspects of performance.[2]

Function

There are multiple forms of debriefing when it comes to content. Promoting excellence and reflective learning in simulation (PEARLS); team-guided team self-correction, advocacy-inquiry, and systemic-constructivist (TeamGAINS); defusing, discovering, and deepening (3D); gather, analyze, and summarize (GAS) are just some of the forms that debriefing can take and are described elsewhere. Regardless of the content, debriefing is rooted in providing learners with a psychologically safe environment. Learners and faculty should have a shared mental model and an underlying assumption that everyone wants to learn and improve upon their current foundation of knowledge.

Issues of Concern

Debriefers should be trained to recognize and intervene in difficult situations so that the benefits of simulation are not compromised. Common surface issues include quiet learners, disengagement, conversation domination with or without proper knowledge and insight, and emotional reactions.[3] Debriefers should also be aware of cultural differences that may affect how learners react and interact in the reflection period after the simulation.[4]

Clinical Significance

Why should you debrief?

Debriefing is one of the most important aspects of simulation design. This component allows learners to reflect on tasks that they performed well, tasks that need improvement, and the opportunity to clarify knowledge gaps.  The debriefing process facilitates adult learning, enhancing self-efficacy and responsibility in the learning process. In doing so, learners can add to their working body of knowledge, promoting the transfer of learning, and faculty and learners can share a similar mental model of benchmarks.[5][6] Research has shown that learner-centered activities contribute to more prepared graduates than those who participate in instructor-centered courses.[7] 

Rapid cycle deliberate practice

Stop-and-go debriefing has been utilized in simulation scenarios focused on mastery learning. This process has gained momentum as the theory behind its use contributes to more opportunities to hone skills, especially for high-stakes clinical scenarios, such as resuscitation. This process is also known as rapid cycle deliberate practice (RCDP).[8] During RCDP, learners can practice one skill set until achieving mastery, and then, in a step ladder approach, more complex action items are added. After each phase, small debriefings take place with feedback and discussion taking place. During a traditional reflective debriefing, learners and faculty debrief after the scenario and may not have the opportunity to practice the scenario immediately.

Debriefing on demand

Debriefing on demand can help in scenarios that have the potential to generate stress and anxiety. One study examined the benefits of this model with novice postgraduate residents. Guided facilitation through complex problems could occur when a learner identified a point in time during the scenario when he/she became overwhelmed or perplexed. The scenario can pause in place and resume during a quick period of reflection. Learners identified that this process allows for clarification and decreased stress, thus contributing to knowledge retention and transfer of skills more effectively.[9]

Video-assisted debriefing

The theory of video-assisted debriefing (VAD) allows learners to review the actual performance of the scenario instead of recalling and relying on other individuals to correctly relay information. Conversely, learners often resent having themselves video recorded, becoming self-conscious.[5] This process has also been utilized for task training skills, such as suturing and laparoscopic techniques. This particular method is proper for remote mentoring.[5]  VAD is also helpful when multiple individuals actively participate in the simulation and when various critical action items require monitoring. It can also help learners gain insight into less objective behaviors such as body language.

Instructor vs peer-led debriefing

Properly trained faculty requires a significant investment and time. Programs that have a large volume of students have been leaning towards the use of peer-led debriefing. While some studies point to virtually no or minimal differences in knowledge and self-confidence, the quality of debriefing does differ with learners noting that instructors provide more feedback and solutions.[10] An added benefit of peer-led debriefing is facilitating collegial skills, mutual respect, and learner bonding.[10]

Written tools for the debriefer

The art of debriefing requires training and expertise.  Written tools have been designed to facilitate debriefing to ensure that the process maintains a learner-centered focus and remains nonjudgmental. These tools can be particularly beneficial to novice debriefers. Debriefing sessions performed by faculty who lack adequate training can disrupt the tenets of simulation, threatening knowledge retention and creating an unsafe environment.[3]

Written debriefing for the learner

There has been some investigation into the potential to incorporate written debriefs in the post-simulation period. The theory is that written debriefs can lend themselves to higher insight into the individual learning process.[3] Learners received the option to participate in an oral debrief versus journaling. In this small cohort, learners benefited more from the oral debriefing process and cited that written debriefs were often a hassle.

Co-debriefing

The process of co-debriefing can be challenging; both individuals need to have a shared understanding of the process, along with mutual respect.[11] A recent publication highlighted some of the challenges of co-debriefing and how to prevent issues from occurring. For example, co-debriefers should position themselves across from each other so that nonverbal cues can help coordinate the conversation and segue into subsequent topics. Co-debriefers should also remain cognizant of how their contribution may interrupt the other individual's thought stream.[12]

Pearls and Other Issues

Other valuable information concerning debriefing theories include:

• Debriefing is a critical component of simulation exercises. Without debriefing, incorrect mental models are often reinforced rather than corrected.
• A preconceived debriefing plan is essential to ensure the addressing of critical actions.
• Effective debriefing requires training and practice.

Enhancing Healthcare Team Outcomes

Debriefing in interprofessional groups allows learners the opportunity to discover how teams can function together, communicate more effectively, and better understand each other’s roles.[13] The role of the debriefer becomes crucial when dealing with interprofessional teams as multiple aspects need to be addressed due to the variable scope of practice amongst the participants and how interdependence can affect team members.[11][14] The debriefing should also focus on remediating an individual’s performance versus the team's performance.[14]