Debriefing

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Debriefing, 听取汇报, comentários, maoni,フィードバック,
terugkoppeling,‫ ردود الفعل‬, প্রতিতিয়া, Rückkopplung, thông tin
phản hồi, обратная связь, Debriefing, 听取汇报,
comentários, maoni,フィードバック, terugkoppeling, ‫ردود‬
‫عل‬, প্রতিতিয়া, Rückkopplung, thông tin phản hồi, обратная
связь, Debriefing, 听取汇报, comentários, maoni,フィード
バック, terugkoppeling,‫ ردود الفعل‬, প্রতিতিয়া, Rückkopplung,
thông tin phản hồi, обратная связь, Debriefing, 听取汇报,
comentários, maoni,フィードバック, terugkoppeling, ‫ردود‬
‫الفعل‬, প্রতিতিয়া, Rückkopplung, thông tin phản hồi, обратная
связь, Debriefing, 听取汇报, comentários, maoni,フィード
バック, terugkoppeling,‫ ردود الفعل‬, প্রতিতিয়া, Rückkopplung,
Geoffrey T. Miller
Assistant
Professor, School of
Health Sciences
thông tin phản hồi, обратная связь, Director
Debriefing,
听取汇报,
Simulation, Technology and Research
Sentara Center for Simulation and Immersive Learning
comentários, maoni,フィードバック,
terugkoppeling,
Eastern Virginia Medical School
‫ردوعل‬, প্রতিতিয়া, Rückkopplung, thông tin phản hồi, обратная
связь, Debriefing, 听取汇报, comentários, maoni,
The Art and Science of
Debriefing
Bottom line, up front…
Debriefing is an art form…
One which is honed through
repeated practice, and experience…
There are many approaches and techniques…
And very few absolute rules
Sessions aims
Identify the goals of debriefing.
Discuss the elements of debriefing that
improve outcomes.
Identify various approaches to debriefing.
Discuss the process of debriefing.
Human processing in action…
ARE YOU
NO
HAPPY?
CHANGE
SOMETHING
YES
DO YOU
WANT TO
BE
HAPPY?
KEEP DOING
WHATEVER
YOU’RE
DOING
YES
NO
Human processing
Natural order
of human
processing
Reflect on it
Experience an
event
Discuss it with
others
Learn & modify
behaviors based
on the
experience
Why feedback/debriefing matters…
B
C
D
A
A = Education
A
B = Things you
know
C = Things you
know you
don’t know
A
D = Things you
don’t know,
you don’t
know
Feedback…
Debriefing…
isn’t it all just the same thing?
Feedback
Feedback comprises a wide array of informational
inputs, which may occur prior to, during, and after
an experience
Feedback is the most important feature of
simulation-based learning
Knowledge of performance results - key to learning
Appears to slow the decay of acquired skills
Allows for self-assessment
Issenberg SB,McGaghie WC, Petrusa ER, Gordon D, Scalese RJ (2005). Features and uses of high-fidelity medical simulations that
lead to effective learning: a BEME systematic review. Medical Teacher 27(1): 10–28.
Feedback sources
Pre-briefings, instructions, in-case sources, debriefings,
peers(team members), log files [manikin, computer, etc],
standardized checklists, rating forms, evaluators (faculty,
peer, patient), recordings (video)…
The KEY is to use multiple sources of feedback… share them
with the learner
Develop a plan for feedback that supports the individual
and/or team learning goals
Debriefing
• A deliberative, learner-centric process designed to
standardize the instructor/student post-event
interaction to assist learners in thinking about:
• What they did,
• When they did it,
• How they did it,
• Why they did it and
• How they can improve.
Factors influencing debriefing
Objective of the experiential exercise
Complexity of the scenario
Experience level of participants
Experience level of participants with simulation
environment
Time available for the session
The role of the simulation in the overall curriculum
Individual personalities and relationships, if any, between
the participants
Debriefing myths… and realities
Debriefing myths…
“There is a highly defined process or method for
conducting learner debriefing”
Realities…
“there are surprisingly few papers in the peer-reviewed
literature to illustrate how to debrief, how to teach or
learn to debrief, what methods of debriefing exist and
how effective they are at achieving learning objectives
and goals”
Fanning, RM, Gaba, DM. The Role of Debriefing in Simulation-Based Learning. Simulation in Healthcare. Vol. 2, No. 1, Spring 2007.
Debriefing myths…
“The most effective facilitation is achieved when the
learners or participants do all of the talking…
not the instructor”
Realities…
Some learners or learner groups may lack an adequate
understanding of the event and it’s elements,
or posses enough prior learning and experience
to effectively reflect and learn.
Debriefing myths…
“Debriefings should always be conducted
in a separate space or environment”
Debriefing myths…
“Debriefings should always be held
after the simulation ”
Realities…
“in certain circumstances (teaching a technical skill,
fatal errors, or seriously flawed behaviors), debriefing
may need to occur during the simulation (AKA: in-
scenario debriefing)”
Debriefing considerations
The ultimate failure of debriefing
“Learners are left with the mistaken impression
that they are doing just fine”
“Ignorance more frequently begets
confidence than does knowledge”
Charles Darwin – The Descent of Man (1871)
Identifying & closing the gaps
Observable performance
Performed well
Performance perception
Feels good
Performed well
Feels bad
Performed poor
Feels poor
Performed poor
Feels good
Knowledge
Skill
Behavioral
GAP
Simulation-debriefing relationship
Activated
Stressed
Upset
Nervous
Tense
Excited
Alert
Elated
Happy
Simulation
Debriefing
Unpleasant
Bored
Sad
Fatigued
Depressed
Pleasant
Relaxed
Serene
Content
Calm
Inactivated
Coaching, prompting & cueing
Coaching
Directing, instructing and training a
person or group of people, with the
aim to achieve some goal or develop
specific skills
Instruction
Prompting
To move to action
Cueing
Giving verbal or non-verbal
triggers/clues for an action to be
carried out at a specific time
Facilitation
Debriefing ‘Dose’
Debriefing Amount/Time
“Debriefing Amount /
Time will decrease
with higher learner
expertise, It will not
reach zero”
Learner Expertise
Novice
Expert
Lots of debriefing modes
Private bedside debrief by facilitator
immediately post scenario
Private ‘debriefing room’ debrief by
facilitator immediately post-scenario
Debrief by peers outside of simulation
suite
Self-guided reflection of video
performance
Feedback, debriefing & deliberate practice
Sim
Prep
Sim
Change
Debrief
Prep
Change
Debrief
Sim
Prep
Change
Debrief
Ericsson’s Model of Deliberate Practice:
“Practice does not make perfect…
practice makes permanent”
Ericsson, KA. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related
domains. Academic Med. 79(10 Supplement):S70-81.
Important debriefing points/skills
Be genuine and student centric
Ask open not closed ended questions:
DON’T- Did you have a good experience?
DO- Tell me about your experience.
Use pauses and silences to elicit feedback
Use probing inquiry to gain deeper understanding
Perspective on use of video
Use if necessary; typically to observe specific
events or processes
Have participants compare their memory with
the recording- “Tell me what happened”
Peer input can be inappropriate- facilitator
needs to guide the discussion into positive
channel
Debriefing Models
Structured & supported debriefing (SSD)
Developed in collaboration with American Heart Association
Definition of ‘structured and supported’
Structured elements include three specific debriefing phases
with related goals, actions, and time estimates.
Supported elements include both interpersonal support as well
as use of protocols, algorithms, and best evidence to inform
debriefing statements/questions
Other considerations
Simple, can be learned rapidly, scalable, validated by practice
Adapted from: O’Donnell, J.M., Rodgers, D.L., Lee, W, W., Edelson, D. P., Haag, J., Hamilton, M. F., Hoadley, T., McCullough, A., Meeks, R., (2009),
Structured and Supported Debriefing [Computer Software]. American Heart Association, Dallas, TX.
GAS Model
Goal:
Actions:
GATHER
Listen to participants Request narrative from
team leader
to understand what
they think & how they
feel
Request clarifying or
supplemental
information from team
25%
Sample Questions:
All: “How do you feel?”
Team Leader: “Can you
tell us what happened?”
Team members: “Can
you add to the account?”
GAS Model
Actions:
Sample Questions:
Facilitate reflection
on & analysis of
actions
Review accurate record
of events
“Tell me more about…”
ANALYZE
Goal:
Report observations
(correct & incorrect
steps)
Reveal participants’
thinking processes
50%
Reflect on performance
Assure continuous focus
on session objectives
“What were you thinking
when…”
“I understand, however,
tell me about “X” aspect
of the scenario…”
“Let’s refocus… what’s
important is not who is
right but what is right for
the patient…”
GAS Model
Actions:
Sample Questions:
Facilitate
identification &
review of lessons
learned
Participants identify
positive aspects of team
or individual behaviors
& behaviors that require
change
“List two actions or
events that you felt were
effective or well done”
SUMMARIZE
Goal:
Summary of comments
or statements
25%
“Describe two areas that
you think you/team need
to work on…”
Plus- Delta
A student-centric approach simulation debriefing using a 2 X
2 matrix. Designed to rapidly gain participant feedback on
both instructor and participant performance
Debriefing With ‘Good Judgment’
Trainee ‘Frames’ Approach
A frame is the internal trainee
environment
Frames to Actions to
Results
Perceptions, knowledge,
assumptions, feelings, training
etc….
Instructor role- ‘cognitive
detective’
Tries to figure out frames
through using a ‘stance of
curiosity’
Genuinely curious inquiry
Advocacy and Inquiry model
Rudolph, J.W. et al., Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiol Clin 25
(2), 361-376 (2007).
“Phased-domain” debriefing
Teamoriented
simulation
GROUP
Teamoriented
debriefing
Domainoriented
debriefing
MD
Domainoriented
debriefing
RN
Domainoriented
debriefing
SA
GROUP
Summary
A few final thoughts…
New role for debriefing?
To learn the skills to recognize ones own “limitations”
(also described by some as incompetence)
“To have such knowledge would already be to remedy
a good portion of the offense” (Miller, WI. 1993)
A possible future…
Debriefing and feedback become normative processes
encompassing all levels, domains and professional
identities of the healthcare system
A final note…
Any simulation activity is a “snapshot-in-time”,
It is reflective of the performance and behaviors which
occurred during that specific time interval,
It is not a positive or negative predictor of future performance
Summary
Simulation-based learning activities are supported by
instruction (coaching) and facilitation (prompting and cueing)
Consider the types of feedback available, and employ those
best suited to achieve the desired outcomes
Formulate a plan to provide structured debriefing following
simulation activities
Debriefing should be learner-centric and conducted within
a safe environment
Participants need and value the feedback
Debriefing points are derived through setting appropriate
session/ course objectives
Questions and discussion
For additional information…
Geoffrey T. Miller
Assistant Professor, School of Health Sciences
Director Simulation, Technology and Research
Sentara Center for Simulation and Immersive Learning
Eastern Virginia Medical School
[email protected]

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