The Art and Science of Debriefing | Maria Overstreet

Report
Maria Overstreet, PhD, RN, CCNS
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Nashville Native
History: Nurse for 25 years
Simulation: just happened into it…
Debriefing: Chose to perform research
Simulation Consultant: Enjoy doing!
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Learner will become more knowledgeable of:
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Debriefing in respect to:
 History
 Meaning
 Concepts
 Methods
 Application
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Has anyone ever facilitated a simulation
debriefing?
How do you define Debriefing?
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WWII, Army’s chief historian, Brigadier
General Marshall
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Performed 1st Historical Group Debriefing (HGD)
 Soldiers recounted events of combat, feelings, &
decisions
 Unexpected finding was psychological benefits
 Termed Spiritual Purging symbolizing cleansing of one’s
actions during combat
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Fillion, Clements, Averill, & Virgil (2002), MacDonald (2003)
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Mitchell (1983) a psychologist
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Worked with emergency services personnel
Developed method of debriefing
 Critical incident stress debriefing (CISD)
 Recount events, discuss actions/decisions, discuss feelings
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Dyregrov (1989) adapted Mitchell’s technique
 Emphasized process and flexibility
 Particularly time and routine
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Red Cross Debriefing of 1989 San Francisco
earthquake
Found small group size allowed for more
intimate exploration of worker’s thoughts &
feelings (12-15 for 2 hours).
Concurs with Dyregrov 2 factors important:
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Time & timing
 Length of time of debriefing
 Proximity to the event
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No works from education literature are
evidence based research studies.
Provide important theoretical and conceptual
information
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Lederman (1984) differentiates educational
debriefing from other debriefings due to emphasis
on the learning derived from the experience.
 Proposed term “postexperience analytic discussion
process” (Lederman, 1984, p. 415)
 Refined term to “cognitive assimilation of experience”
Author/Year
Important Concepts
Lederman (1984)
Lederman & Ruben (1984)
Assist learner in new ways of seeing, perceiving, &
making sense of experience
•Educator must master skill of timing: when to
select right time for discussion
Pearson & Smith (1986)
Provide structure for debriefing process with 3
segments in question format:
“what happened?”, “how did participants feel?”, &
“what does it mean?”
Includes aspects of military, psychological, &
educational debriefing.
•Requires educator with strong interpersonal &
interventionist skills & skill of timing.
Author/Year
Important Concepts
Sims (2001)
A cognitive activity, “post-experience analysis”
(Sims, 2001, p. 179)
Utilizes Kolb’s model of learning to structure
specific questions
•Time in debriefing influenced by purpose,
complexity, intensity, student responsiveness, &
format.
Petranek (2000)
Extends experiential learning activity and assists
learner with reflection with written debriefing,
allows for time to process and gather thoughts
•Primary ingredient for valuable reflection: time
elapsed
Author/Year
Important Concepts
Rudolph, Simon, Dufresne,
& Raemer (2006)
Developed their debriefing practice to
acknowledge importance of 2 aspects: timing &
relationships.
Timing is immediacy to event
Relationships between educator & learner
defined with trust & respect
Consistent with psychological debriefing
Rudolph, Simon, Rivard,
Dufresne, & Raemer (2007)
Utilize educational learning theory: Double loop
learning (Argyris & Schön, 1978) to base their
practice of debriefing.
•Developed communication technique,
advocacy & inquiry.
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Communication
Discussion of events: What happened?
 Language use: words & body
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Time/Timing
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Time is a controversial factor
 How long, who speaks for how long, & role of silence
 Timing: when to introduce or stimulate a discussion
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Emotion
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Attention to the affective domain: feelings & emotions
Structure
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Pattern of organization, how it flows; anticipation of
learner of what is to come
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Points to VALUE of debriefing
Savoldelli, et al (2006)
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Verbal & verbal + video improved skill performance
Jefferies & Rizzolo (2006)
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Learner identified debriefing as the most important
design feature of simulations
Learner’s self-confidence ratings increased with
active learning followed by reflective exercises
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Lasater (2007)
Studied simulation & critical thinking
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Comments on necessity of assisting students to cope
with their emotions following simulation
 Addresses the affective domain of learning
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Johnson-Russell (2007)
Presents a loose structure for debriefing
Refers to 4 stages:
1.
2.
3.
4.
Introduction
Personal reaction [psychological component]
Discussion of events [What happened?]
Summary [Synthesis of knowledge, meaning
making]
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Dewey (1938)
Learning by doing
Not every experience results in education or
learning
LEARNER must:
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Interact with environment
Make meaning of the experience from past, present,
or future
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Debriefing by Dewey’s theory of experiential
learning…
Reflective component
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Provides opportunity to link knowledge and
experience or knowledge, skill, and meaning derived
by the learner
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Kolb (1984)
Experiential learning model
Represents 4 cyclic stages learners venture
through to understand experiences
Reflective Observation
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Discuss experience, ponders what went well & not,
seeks affirmation or learns alternative method, gains
insight
Concrete
Experience
Knowledge, skill,
attitude, experience
during clinical
Abstract
Experience
Knowledge, skill,
attitude,
experience
during simulation
Reflective
Observation
Debriefing process
Rich discussion of events
and how to manage
differently or how managed
well
Abstract
Conceptual
ization
Debriefing Process
Able to view situation
in various contexts:
different disease
processes or patient
response
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Schön (1987)
Learning through reflecting as it relates to
practice professions
Isolated reflection & expanded on its meaning
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2 methods of reflection in practice:
 Reflection in action (thinking while performing)
 Reflection on action (pose ? To self to change)
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Overstreet (2009)
Qualitative study
Case study design (4 independent cases)
Data
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Observation & field notes
Video of debriefings
Facilitator interview
Facilitator questionnaire
Student questionnaire
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Original 4 concepts from literature emerged
Communication
 Time/Timing
 Structure
 Emotion
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Triangulation of data sources: from both
students and facilitators
Accentuate the positive
 Higher Order Thinking
 Experience Counts
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Qualitative Research
 Explore phenomenon through identifying idiosyncratic
patterns of behaviors
 When little is known
 Madjar & Walton, 2001
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Case Study
 Investigate a contemporary phenomenon within its
real-life context
 Multiple sources of data
 Yin, 2003
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Teacher
 Student
 interaction
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Process
 time spent in certain aspects of exchange
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Content
 what is communicated
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IRB Approval
Protocol remained same for each data
collection
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Observe
Videotape
Student Questionnaire
Educator Semi-structured Interview
Educator Questionnaire
Field Notes
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Triangulation of multiple data sources
Categorical aggregation
Time-ordered analysis
Pattern matching
Cross-case synthesis
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Pre-simulation – 30
Simulation – 30
Debriefing – 25
Content – Med/surg
Students – 6 (22 yr old)
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Silent
Minutes
2
8%
AD, (1 AA, 5 Cau, 1♂)
Educator – Cau, ♀
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Students
Talk
Minutes
5.22
21%
23 yr RN, used personal
storytelling for emphasis
Tone - Natural
Educator Talk
Minutes
Educator
Talk
Minutes
18.08
71%
Students Talk
Minutes
Silent Minutes
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Pre-simulation – 5
Simulation – 105
Debriefing – 47
Content – Skill practice
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Students – 7 (22 yr old)
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Communication w/pt.
BSN, (1AA, 6 Cau, all ♀)
Educator – 2, Cau, ♀
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14 & 4 yrs RN
Structured, safe & trusting
atmosphere
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Pre-simulation – 5
Simulation – 50
Debriefing – 28
Content – Cardiac/ED
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Students – 3 (38 yr old)
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Decisions at point of care
BSN, (All Cau, 1 ♂,
previous roles)
Educator – 2, Cau, ♀
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18/10 yr RN
Feedback(-),(93 ?/20min)
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Pre-simulation – 5
Simulation – 90
Debriefing – 38
ContentSepsis/ED/ICU
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Decisions at point of care
Educator Talk
Minutes
Student – 7 (22 yr old)
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Student Talk
Minutes
5.05
13%
Silent
Minutes
2.5
7%
BSN, 1 AA, 1 ♂
Educator - ♀ Cau.
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38 yr RN/34 yr teaching
Interweave of emotion
Educator Talk
Minutes
30.35
80%
Student Talk
Minutes
Silent Minutes
Percentage of Time by Case
100%
80%
8%
20%
0%
49%
20%
9%
7%
13%
60%
40%
20%
Silent
72%
51%
71%
80%
Students Talk
Educator Talk
0%
Case 1 Case 2
Case 3 Case 4
CASE 1
CASE 2
CASE 2
CASE 3
CASE 3
CASE 4
Educator 1
Educator 1
Educator 2
Educator 1
Educator 2
Educator 1
TAUGHT AT INSTITUTION
23
3
0
2
2
3
14
7
5
2
2
3
4
0.5
0.5
0.5
0.5
0.5
18
4
3
0.5
0.5
4
10
5
5
1
0.5
5
38
34
34
2
3
5.5
HIGHEST DEGREE
BSN
MSN
MSN
MSN
MSN
DNP
TAKEN EDUCATION COURSES
Yes
Yes
No
No
No
Yes
READ ABOUT DEBRIEFING
Yes
No
No
Yes
No
Yes
ATTENDED
CONFERENCE/WORKSHOP
Yes
Yes
Yes
No
No
Yes
HOW LEARNED DEBRIEFING
METHOD USED
Trial & error,
Jeffries book,
internet search
Conferences and
individual teaching
session
Life experiences
Talking with
students in clinical
Trial and error,
watching others
Reading, doing,
and making
adjustment
YEARS AS RN
TAUGHT CLINICAL
TAUGHT CLASSROOM
TAUGHT SIMULATION
TAUGHT DEBRIEFING
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Structure
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All 4 heavy in structure, physical environment
 Case 1: driven by written questions
 Case 2: (+) peer feedback
 Case 3: knowledge questions
 Case 4: less defined: variety of teaching methods
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Communication
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Listening: to hear with thoughtful attention
Language: words, pronunciation, includes tone and body
Pattern frequencies: links, swoops, timing
Case 4 – swoop 8 times / Case 2 – no swoops in analysis
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Time
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Time spent in debriefing – 25-47 min.
Educator talk time 18 – 30 min.
Silence 0 – 5 min.
Case 2: Outlier student talk time
Case 3: Students answered 57 X in 2.5 min(2.6 sec/answer)
Emotion
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Case 1 & 4: Storytelling and interweave of emotion
Case 3: Negative vs positive feedback (18/9/5)
 “I was thinking their knowledge base was a little more than what it may
have been”
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Accentuate the Positive
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Higher Order Thinking
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Experience Counts
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Educators unanimously perceived students &
themselves (+)
 “I try to end it in a positive by asking the students a couple of
things they learned today that they didn’t know before…”
 “Cause we want them to leave feeling positive about simulation and
not being terrified and being embarrassed cause we are using
simulation in every single course”
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Students: What did today’s debriefing mean?
 “It was feedback I needed to hear. It helps me identify + and -.”
 “to discuss people’s strengths and areas that need to be worked on
in a positive manner”
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Putting It All Together
 Meaning making: Students
 “Debriefing just put all the pieces of the puzzle together”
 “Debriefing helped to pull everything together & make sense of it
all”
 Meaning making: Educators
 Case 1: predetermined goal to connect theory & practice
 Case 2: tie together student improvement
 Case 3: tried to tie together knowledge from simulation
 Case 4: cannot refrain from teachable moment
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Decision Making and Critical Thinking
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Case 1 & 3: Dialogue about how decisions were made
Case 3: “You get to find out more about what they were thinking…”
Case 2: Skill focused: therapeutic communication process
Case 4: minimal skill focus, knowledge questions to ponder,
overlaid with attention to attitude
Students: “Helps you learn & think critically” “to focus on your
patient & not the monitors. Also it is important to think critically &
prioritize your care”
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Educators brought themselves to debriefing
More experienced vs. less experienced
Students value experience
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“We practiced on a plastic dummy which just
increased our chances of responding appropriately to
the situation in real life”
Strengths
Design
•Strategies to
increase
trustworthines
s
Limitation
s
Generalizability
Triangulation of
multiple data sources,
Peer review,
Identification of own
biases
Small sample size: 4
cases
Strategies to
strengthen validity
Potential Effects of
Direct Observation :
Categorical
aggregation, Timeordered analysis,
Pattern matching,
Cross-case synthesis
Hawthorne, Halo,
Error of Leniency and
Error of Severity
Participants:
University, Educator,
& Student
Limited camera view
of student
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Theory
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Literature
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Military, Psychology, Education
Concepts
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Dewey, Kolb, Schön
Communication, Time/Timing, Structure, Emotion
Research Patterns
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Accentuate +, higher order thinking, experience
counts
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Information to consider as you develop your
own style of debriefing
Ask yourself the question
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How will I address these concepts in debriefing?
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Objectives for simulation add depth to
debriefing
Are you going to allow the objectives for the
simulation to guide the debriefing, structure
the debriefing, limit the debriefing…
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View code simulation
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What is the objective for the simulation?
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1.) to feel the urgency of being involved in a code
situation?
2.) to administer accurate CPR?
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Will you be very rigid with time
Will you be lax with time
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Literature points to time as important:
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How long? … As long as the experiential learning
For true reflection – have to spend silent time
thinking
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Video tape yourself…you will learn a lot!
Language is a powerful tool.
Example: [ + / Δ ]
How do you communicate this to the learner?
What was good/bad?
What was done well/what can be improved?
How do you list these items?
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Include the learner in coming up with the items
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Theory
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Literature
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What literature you produce
Concepts
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Your theory
Concepts you discover in your practice or observe in
other’s practice
Research Patterns
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Patterns you produce or you observe

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