Debriefing Techniques Utilized in Medical Simulation

Function

Common Rules and Essentials of Effective Debriefing

In healthcare, multiple techniques and debriefing models have been proposed and utilized, but a gold standard debriefing technique remains unidentified.[10] Despite the diversity of debriefing techniques and frameworks, the majority involve similar “essential” elements described by Cheng (Table 1). These essential elements ensure the safety and efficacy of the debriefing environment regardless of the debriefing setting, the reason for debriefing, or the technique used.[3]

 Table 1: Essential Elements of Debriefing and its Characteristics

1. Ensuring psychosocial safety

• ‘‘Behave or perform without fear of negative consequences to self-image, social standing, or career trajectory.”
• Essential to optimize learning outcomes by providing a supportive climate
• This should be conducted during the pre-simulation briefing and then during the debriefing

2. Having a debriefing stance or ‘‘basic assumption,’’

• Predefined basic assumption statement, “We believe that everyone participating in this simulation is intelligent, capable, cares about doing their best, and wants to improve.’’

3. Establishing debriefing rules

• A basic set of rules for debriefing among participants
• Confidential discussion
• Encourage all learners to participate actively

4. Establishing a shared mental model

• Review the event details with input from the facilitator

5. Addressing Key Learning Objectives

• Incorporate and analyze clear learning objectives during debriefing

6. Using open-ended questions

• Helps facilitate discussion and foster reflection
• Avoid close-ended or (yes/no) questions

7. Using silence

• A brief period of silence after a facilitator asks a question
• Promote an internal process within the debriefing learner’s mind
• Allows learners to formulate their thoughts and analyze their mental frames

Issues of Concern

Debriefing Techniques in the Simulation Literature

The science and the art of SBE debriefing have rapidly evolved with the exponential growth of SBE over the last 2 decades. There are descriptions of several diverse models.[10] Although the core of the debriefing process centers on the reflection part of the simulated exercise, there are usually phases that allow this to happen in a structured manner. Many debriefing techniques run naturally through 3 main phases: reaction/description, analysis/understanding, and application/summary, as listed in Table 2.

Table 2: Common Phases of the Debriefing Process

PHASES

1. Reaction/Description

• Time for learners to diffuse and decompress, "blow off steam"
• Open-ended questions about how learners feel?
• Review the facts of the event

2. Understanding/Analysis

• Preview topics/learning objectives
• Explore, discuss, inquire
• What happened? Why did it happen?

3. Application/Summary

• "Take-home messages."
• Apply learning experience to a future encounter
• Allow for learners' questions

However, sometimes debriefings move out of their traditional format based on many factors, including the complexity of the scenario, learners' experience, the amount of time allotted for the simulation exercise, the number of facilitators, or the debriefing skills of the facilitator. To date, no evidence supports 1 debriefing technique over another, leaving space for educators in simulation programs in healthcare to adopt their debriefing techniques based on the factors above. 

A facilitator-guided post-event debriefing involves a "debriefer(s)" facilitating a discussion after a simulation event. The role of the facilitator could also be to act as a guide before the simulation (pre-briefing) and during the simulation. The facilitator directs and/or redirects the discussion when needed and ensures that learning objectives get discussed and that the debriefing process is flowing smoothly. The facilitators should position themselves as co-learners, not as a traditional "teacher."[1][10] The level of facilitation and the degree to which the facilitator is involved in the debriefing process depends on many factors like the complexity of the scenario, allotted time and levels, and learners (novice vs. experienced) or learners' personality traits (difficult vs. quite vs. defensive vs. others). This article lists described techniques and tools for debriefing and delineates significant differences and similarities between these techniques when conducting debriefing in the simulated setting. The detailed aspects of the role of the facilitator in the debriefing process are beyond the scope of this article

Common Debriefing Techniques

In a recent review article, Cheng et al emphasized that almost all debriefing methods are likely effective if used appropriately by well-trained facilitators. Additionally, a specific debriefing method or technique becomes less important than debriefing the act itself.[10] Given the nature of this article, we did not necessarily attempt to quantify different debriefing techniques or grade the level of evidence; instead, we are providing educators and facilitators with a "toolkit" for debriefing that they can choose from depending on their skill set, and preference, learning environment, and contexts. These debriefing techniques are summarized in Graph 1.

• Plus-delta

One of the most straightforward models among debriefing techniques involves using 2 columns, where the plus column (+) refers to good behaviors or actions. In contrast, the delta refers to behaviors or actions that need improvement or change in the future. This technique allows learners to participate in the discussion and is easily utilizable by novice debriefers.[7][9]

• 3-phase debriefing technique

Many "3-phase" techniques have been developed for use in debriefing. Rudolph et al described a debriefing model called "Debriefing with Good Judgment," where the debriefing session comprises reaction, analysis, and summary (RAS).[11] The reaction phase allows for exploring participants' responses and defusing following the simulation event.

A common question during this phase is "how did that feel?" which allows the facilitator to hear initial reactions, validate emotional responses, and take notes for the next debriefing phase. The analysis focuses on understanding what, why, and how actions evolved during the scenario. It allows both the facilitator and the learners to investigate the gaps noted during the scenario, understand the rationale behind it, and work together toward closing the gap and reflective discussion. A common theme applied during this phase is the advocacy inquiry, where the debriefer tries to unveil the learner's frames.   Lastly, the summary phase focuses on lessons learned during the analysis phase and prepares "takeaway" points by learners. Other similar 3-phase techniques have been described by different educators, including the 3D model (defusing, discovery, and deepening), GAS (gather, analyze, and summarize), and the Diamond debriefing, which includes description, analysis, and application.[8][12][13]

• Multiphase debriefing techniques

Several "multiphase" debriefing techniques have been proposed, with additional phases added to allow focus on key themes of debriefing and support the debriefing conversation. 

Promoting Excellence and Reflective Learning in Simulation (PEARL)

A blended 4-phase debriefing framework, where 3 phases are based on the same framework as RAS, with an additional descriptive phase to summarize key events encountered during the scenario and ensure a shared mental model between the facilitator and learners.[7] This tool has explicit debriefing steps with possible wording choices facilitators can use, making it an easy-to-implement debriefing tool.

Team-Guided Team Self-Correction, Advocacy-Inquiry, and Systemic-Constructivist

(TeamGAINS)

A 6-phase hybrid debriefing technique for team training in simulated events that integrates 3 major key approaches: guided team self-correction, advocacy-inquiry, and systemic-constructivist techniques.[14]

The healthcare simulation after-action review (AAR)

This multiphase debriefing technique is based on the US Army's After-Action Review (AAR). This tool has been used by the US Army and civilian organizations for decades. This tool includes 7 sequential steps and has been proposed for use in the healthcare setting following simulation events. This structured format addresses learning objectives and performance and can provide even novice debriefers with a concise and effective debriefing framework.[9]

Graph 1: Different debriefing techniques utilized in medical simulation

Other Adjuncts and Tools in the Debriefing Process

Given that the facilitator's skills in conducting debriefing are paramount, various faculty development activities for training in debriefing have been described (workshops, webinars, full-day courses, or longitudinal programs). To date, there is no robust evidence regarding the best structure or format of these activities, making the potential of these methods unfulfilled.[1][15] Various debriefing adjuncts have been identified in the literature to help facilitators conduct the debriefing session and promote the learning environment. Chang et al published 3 major adjuncts that facilitators and educators in the simulated setting can utilize (table 3). Additionally, different debriefing online resources have been published and made available for facilitators to foster debriefing practices and support clinical medical educators.

 Table 3: Debriefing Adjuncts

Adjunct  

1. Codebriefing

Benefits

• More than 1 facilitator was involved in conducting the debriefing
• Allows for a large pool of expertise and viewpoint
• Facilitators complement each other style

 Challenges

• Facilitators may have different agenda
• Facilitators interrupt each other
• One facilitator's domination of the discussion
• Open disagreement  

 2. Debriefing Script

Benefits

• This may improve the facilitator's ability to lead the debrief effectively
• It may enhance the acquisition of knowledge  

 3. Video Review

Benefits

• Helps to facilitate by grounding the discussion using the video as evidence
• Highlights areas of excellent and poor performance  

Challenges

• No evidence of its benefit in enhancing educational outcomes when compared to debriefing without video

Clinical Significance

Debriefing is a powerful tool and a robust educational technique in medical education. The widespread use of debriefing in simulation programs has correlated with enhanced team performance and improved behavioral and technical skills of providers in simulated settings. Debriefing following clinical events has evolved in the last 2 decades and has improved clinical performance and patient care.[4][16] Promising research studies demonstrated the utility of post-clinical event debriefing in the acute care setting, particularly in the emergency department and the intensive care setting, in the context of rare and stressful events like cardiac arrest.[17][18][19][20] More specifically, post-cardiac arrest resuscitation debriefings have correlated with improved compliance with resuscitation guidelines and patient survival and neurologic outcomes.[20] The American Heart Association (AHA) endorses debriefing as a modality to improve the quality of cardiopulmonary resuscitation.

The 2 common debriefing formats following clinical events are hot (immediately, minutes, or hours after the event) and cold (days to weeks after the event). Hot debriefing usually relies on participants' memories and thought processes to discuss the clinical event. It incorporates the “qualitative” debriefing format to assess and address urgent issues following the event. In contrast, cold debriefing incorporates formal “quantitative” debriefing with a collection of quantitative data and follow-up patient information to enhance quality improvement opportunities and system improvement.[16][17][18]

Conclusion

Debriefing is the cornerstone of effective simulation-based medical education. While the evidence-based gold standard debriefing technique is yet to be determined, most of these techniques are likely effective if utilized appropriately by educators and facilitators. 

Enhancing Healthcare Team Outcomes

Simulation debriefing can improve performance across many medical disciplines, including clinicians, nurses, pharmacists, and other allied healthcare providers. All healthcare team members involved in simulation and debriefing must have open communication channels to provide optimal feedback to the learners so they can focus on areas for improvement and replicate their strengths in the future.