The Art and Science of Debriefing: a Simulation

Experience

Mary Cantrell, MAPULSE Center – Director

Arkansas Children’s Hospital

Debriefing

The most important aspect of running any simulation -

Debriefing

“Simulation is just a good excuse to do debriefing”

Dan Ramer

Learning Model

Unconsciously – Incompetent

Consciously - Incompetent

Consciously – Competent

Unconsciously - Competent

Your Best Teacher was…

• Smart• Wise• Caring • Concerned• Unspoken expert

How people practice

Internal Frames

• EXAMPLES: • Thanksgiving is a day I eat all my

favorite food.• Dancing makes me look goofy• If I don’t leave work by 4:45 I will

be stuck in traffic.

Learners Frames

• Feelings• Assumptions• Knowledge• Stuff I know is true• Stuff I learned in school

Frames shape actions

• Thanksgiving is a day I eat all my favorite food. – Eat all day – I can diet tomorrow.

• Dancing makes me look goofy – Don’t go near the party with a dance floor.

• If I don’t leave work by 4:45 I will be stuck in traffic. - Hurry all day to get it done because I don’t want to get home at 6pm.

Medical Frames & Actions

Residents don’t have any power… and I can’t tell my attending what to do.

When you do airway, you have to use an AMBO bag. I can’t find one and I think this patient is not going to make it.

I just got out of school and everyone thinks I know what I am doing.

How do you define errors?• Intentionally rational action• Seemed like a good idea at the

time, given the circumstances.• Lack of knowledge

Our Basic Assumption

Everyone participating in activities in the PULSE Center is intelligent, well trained, cares about doing their best and they want to improve.

Debriefers Job

• Help learner to surface their frames and analyze the impact on their actions.

• Be the UNSPOKEN EXPERT• Facilitate open/safe discussion

Frames Actions Results

Debriefing leads to new frames

Debriefing changes later actions

Judgmental Statements & Questions

• Can anyone tell us where John made his big mistake?

• Does someone have a clue as to what went wrong with this patient?– Setting them straight – I’m right – You are wrong– I know --- you don’t (essential failure in

thinking)– Truth------error (next time do it my way)– I know the answer- can you guess what I am

thinking? – “pimping”

Non-Judgmental (???)

• I’m right – your wrong – but I don’t want to upset you.

• “Feedback Sandwich”– Something soft (complement)– Something meaty (criticism)– Something soft (complement)

Creates confusionHas hidden truthsConsequences unclear

Debriefing with Good Judgment

• How did the learner make meaning of what happened

• Instructor “From what I know this happened in the simulation and this is where I saw the problems”

• Learner is also smart and well trained trying to do the best so… why did the learner take these actions? (they must have a good reason)

Errors are discussable• Mistakes are made and recognized and

then changes happen • Source of learning happens when you

know what happened and how it can be different

• Make mistakes discussable • Enhance patient safety• Let learners identify their own

mistakes

Debriefing with Good Judgment

• Learner makes a mistakes • Debriefer is genuinely curious• Discuss what that looked like• Learners feel worthwhile and

intelligent• Respectfully insert your expertise• Frame changes can happen!

Debriefing is Discussion (not lecture!)

• The Debriefer should talk less• Try only asking questions• Get the learners to talk to each other• Make it SAFE to discuss • Be a facilitator; not a lecturer• Closed ended questions – as

appropriate• Open ended questions

Three Elements of DebriefingReactions

– Feelings– Facts

Understanding – Explore deeper meaning

Summary– The take home message

Advocacy-Inquiry

• Advocacy – observation, statement, fact - neutral

• Inquiry – question or curiosity*

*GENUINE Curiosity (you want to understand)

Successful Debriefing• Genuinely interested – You see yourself

as the good teacher not the good healthcare worker

• Pre-scenario briefing of expectations• Reinforcing good practice • Correct a limited number of errors• Avoid excessive correction (people only

remember 1 or 2 things - what is the take-home message?)

Successful, Con’t

• Stress key educational points• Use playback so the learners can

see themselves• Talk less, facilitate more• Be respectful of any learner

criticism• Use Advocacy – Inquiry • Plus /Delta

Plus/Delta

Encounter Detractors

• Lack of purpose, objectives• Excessive criticism, negative

feedback• Humiliating a team member• Fixating on medical procedure

Encounter Detractors

• Underestimating the learner’s emotions/feelings

• Lecturing• Hypercriticizing learner’s

performance• Allowing discussion to focus on

limitations of simulation

Debrief Roadblocks

• This would never happen• If this was a real case, I would

have done things differently• No matter what you say, I don’t

agree with you

Good Debriefing Questions• How do you think that went?• What did you do well?• How would you do this

differently next time?• How do you rate your

communication between team members?

Good Debriefing Questions• What was not done?• How did you feel?• What do you think happened?• Has this ever happened to you

in the past, how did you react?

Good Debriefing Questions• What did you see happening?• Would you have done the same

thing as _____?• What information was being

used?• Did you need anything that was

not there?

Thank you!

Mary Cantrell, MAUniversity of Arkansas for

Medical Sciencescantrellmaryj@uams.edu

PULSE Center – ACHcantrellmj@archildrens.org