Taking Simulation & Debriefing to the Next

Level

Taylor Sawyer, DO, MEd, CHSE-ADirector, Neonatal Education and Simulation-based Training (NEST) ProgramUniversity of Washington School of Medicine & Seattle Children’s Hospital,

Division of Neonatology

Disclosure

• Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing health care good or services related to the content of this CME activity

• My content will not include discussion/reference of any commercial products or services

• I do not intend to discuss an unapproved/investigative use of commercial products/devices

Learning Objectives

1. Describe the importance of debriefing in simulation-based education

2. Review core concepts in post-event debriefing3. Discuss techniques for successful debriefing 4. Examine the benefits of ‘debriefing the debriefer’ to improve

debriefing skills

The Importance of Debriefing

How important is Debriefing in Simulation-based Learning?

• Very important • Important • Somewhat important • Undecided • Not important

Why is Debriefing Important?

• Reflection on action is a critical part of experiential learning

• Kolb

• Allows time for self-exploration and feedback

• Feedback/debriefing the most important part of simulation in the literature

McGaghie W, et al. A critical review of simulation-based medical education research: 2003-2009. Med Educ. 2010 Jan;44(1):50-63.

Debriefing Defined‘‘process in which people who have had an experience

are led through a purposive discussion on the experience.’’

-Lederman, 1992

“The act of reviewing a real or simulated event in which participants explain, analyze and synthesize

information and emotional states to improve performance in similar situations”

- Center for Medical Simulation, 2010

Core Concepts in post-event Debriefing

What is Debriefing?

• Debriefing is not lecture• Debriefing is a facilitated discussion among team members about

events that just occurred• The instructor’s job is to enable self-discovery among team members

about • what went well, and why?• what needs improvement, and how?

Feedback vs. Debriefing

Feedback = provision of informationDebriefing = facilitated discussion

• Feedback can occur during debriefing, but debriefing should only be the facilitator giving the participants feedback…

• The amount of instructor feedback needed is inversely proportional to experience of team members

A Successful Debriefing

1. Creates an safe atmosphere where participants can analyze their own behaviors and skills

2. Addresses the most important learning objectives• what went well and what needs improvement

3. Engages all participants in learning4. Results in improved performance

Techniques for successful debriefing

Preparing for Debriefing

• What are your learning objectives for the scenario? • Teamwork/behavioral skills• Technical skills

• Watch for unexpected learning opportunities that require discussion• ‘Emergent’ learning objectives • These may not be on your agenda before the simulation, but are important to

discuss

NRP Instructor’s Role During a Debriefing• Act as a conversation guide • Facilitate the debriefing process • Help learners identify the most important topics

• Lead the discussion to the topic, if needed • Act as a resource for teamwork issues • Act as a resource for technical issues• Keep the discussion learner-centered

• Hold your feedback, unless needed to guide learning

Basic Points for Debriefing Facilitators • Sit forward, do not cross your arms and legs• Be friendly and professional• Use humor carefully• Hold the team accountable for errors

• Help them figure out why errors occurred, and how to prevent them next time

• Use silence. • Count to five (or ten) before talking

• Keep if BRIEF• 5- 10 min max.

Psychological Safety

• Critically important during simulation-based training • Requires a conscious effort, and planning • Suggestions:

• Explicitly mention “safe learning environment” during pre-briefing, or debriefing

• Employ the “Vegas Rule”

How to Facilitate the Debriefing Conversation?

The Beginning of the Debriefing

What’s the first question you ask during a debriefing?

• “How did that feel? ”• “Can you briefly summarize that scenario? ”• “What do you want to make sure we discuss? ”• “What were you thinking…? ”

First Question: “How did that feel?”

Pros:• Allows people to unload emotion• Provides you with an opportunity to assess the feelings of the group• Establishes a safe environment for emotionCons:• Can take more time than you have available • Can result in emotional overload/distraction for everyone (“my

daughter died in a code like this...”)• Those uncomfortable with “feelings” might disengage from the

debriefing

First Question: “Can you briefly summarize that scenario? ”

Pros:• Provides opportunity to ensure everyone has the

same shared mental model • Allow time for clarification about case, if needed • Focuses on medical aspects of the case (no emotions)Cons:• No time for emotional off load • Typically requires follow up question to spark the

conversation

First Question: “What do you want to make sure we discuss?”

Pros:• Learner centered • Allows self-identification of learning points • Can lead conversation rapidly to important topics

• Saves time Cons:• Impressions by a vocal few may influence the group • Conversation may stray from predefined learning

objectives

The Middle of the Debriefing

Your Next Questions?• Progress through debriefing on some type of

agenda • Examples: • Chronologic review of events

• “Walk me through what was happening when you first approached the patient…”

• Point-by-point according to learning objectives • “Let’s talk about communication during that case”

• Observation by observation • “Who was the leader in this scenario?”

Suggested Debriefing Topics…

Why Behavioral Skills?

• Team communication and leadership during neonatal resuscitation correlated with overall quality of the resuscitation and compliance with NRP steps

Thomas EJ. Teamwork and quality during neonatal care in the delivery room. J Perinatol. 2006 Mar;26(3):163-9

Behavioral Skill Correlation P value

Communication 0.236 0.007

Leadership 0.288 <0.001

Sawyer et al. Technical skills and behavioral skills in neonatal resuscitation. J Perinatology. 2014 ;34(10):781-6

Why Behavioral Skills? • High behavioral skills scores associated with improved

technical skills performance and faster times to key steps in resuscitation

Don’t Let Important Points Fizzle - Dig Deeper! • “Tell us more about that…”• “What would have happened if…”• “Talk about that for a moment…”• “Who else observed this? What did you notice, and what were you

thinking about?”• “Why was that helpful?”• “How could your team have helped you?”

Tips and Tricks

• Facilitate, Don’t Dominate• Before making a statement, think about asking a question

instead • Be curious not accusative• Questions: Statements= 3:1

• Avoid yes/no questions What, How, and Why?• Trainee: Instructor speaking= 3:1

• Don’t be afraid of silence!

Teaching During Debriefing?

• Use the responses from participants to identify knowledge/performance gaps

• Provide instruction IF needed to fill the gap• This is where feedback comes in!

Insert Feedback Here

Rudolph et al. Sim in Healthcare. 2006

Mental processes of participants

Using Video During Debriefing?

• Good Points: • Saves time recounting events• Helps learners see what actually occurred• Helps learners see how their behaviors impacted others (positively and

negatively)

• Tips: • Do not show the entire video

• Choose places that merit discussion• Pause the video during discussion

Debriefing with Video – Is it Helpful?

Sawyer et al. The effectiveness of video-assisted debriefing versus oral debriefing alone at improving neonatal resuscitation performance: a randomized trial. Simul Healthc. 2012 Aug;7(4):213-21

Debriefing with Video – Is it Helpful?

Cheng A, et al. Debriefing for technology-enhanced simulation: a systematic review and meta-analysis. Med Educ. 2014 Jul;48(7):657-66.

The End of the Debriefing

Ending the Debriefing

• Conclude on a positive note• Ask summary questions:

• “How has your teamwork improved?” • “What will you do differently next time?”

• Consider polling each participant:• “What have you learned today?”

The goal is performance improvement, not perfection…

Debriefing the Debriefer

How to Improve Your Debriefing Skills?• Practice, Practice, Practice…• Use debriefing skills every day

• Post-event clinical debriefing can utilize the same structure as post-event simulation debriefing

• Video your debriefing and assess your own performance• Get feedback from your colleagues

• “Debrief the debriefer”

COME TO THE ‘DEBRIEFING THE DEBRIEFER’ WORKSHOP THIS AFTERNOON!!!

Conclusions

• Debriefing is THE most import part of simulation-based education • Post-event debriefing should follow a structured approach

• Techniques for debriefing focus on guiding the conversation to achieve learning objectives & performance improvement

• Getting feedback on your debriefings is important to improve skill

Questions?

www.NESTProgram.org or tlsawyer@uw.edu