Introduction
Debriefing can ‘make or break’ a simulator session and can be attributed as the ‘heart and soul’ of simulator training
In his attempts to accurately record events during World War II, US army Chief Historian Brigadier General Marshall performed the first historical group debrief (Shalev, 1993). Using a stepwise approach to the reconstruction of events, soldiers were interviewed as soon after action as possible. The primary aim was to obtain key information to assess performance and gather intelligence to inform future strategies. However, this method of reconstructing events following stressful combat exposure uncovered some unexpected psychological benefits.
The intention here is not to recount a historical evolution of debrief; however, this mix of fact finding, investigation, emotional responses and the development of future strategies is helpful in the formation of a definition. Put simply, in order to build upon past experience and gain knowledge, it is useful to fully perceive and make sense of them. Fanning and Gaba (2007) explain that adult learning is most successful when actively engaging and experiential, ‘not only concrete events in a cognitive fashion, but also transactional events in an emotional fashion’.
The majority of healthcare education is delivered to adult learners. Such learners are usually self-motivated and attend sessions with their own learning objectives; therefore, it is crucial that they are able to participate actively in their education. There is evidence to suggest that without this, the effectiveness of the education provided is limited in this group. However, debriefing like any other skill needs to be learnt and practised and if poorly performed could actually be harmful to the learner(s), so it is important to get it right.
Fanning and Gaba (2007) go on to describe debriefing as a facilitated reflection encounter based upon an experiential learning episode. Any facilitated conversation following critical events, whether those are simulated or actual, is in essence the debrief structure. This conversation is an opportunity to identify any challenges encountered and to discuss and construct solutions. Discussions centring upon what went well are equally important to the process as those aimed at improving future performance.
The importance of debriefing as part of learning has been well documented; it is central to that process and cannot be overstated. There is considerable evidence to show that performance can be improved when debrief is utilised as part of simulation-based education (Small et al., 1999; Shapiro et al., 2004; DeVita et al., 2005; Dine et al., 2008; Morgan et al., 2009). Therefore, debrief is regarded by McGaghie et al. (2010) as the most important variable to produce effective learning from simulation-based medical education, with Rothgeb (2008) arguing that it should always be an integral part of the process. This period of facilitated reflection and discussion allows learners to become critical observers as well as active participants and is a broader description of experiential learning. Participants can ‘take responsibility for their own learning; to be autonomous thinkers, to develop integrated understanding of concepts and to pose and seek to answer important questions’ (Brooks and Brooks, 1993). The significance of the debrief as an essential part of the learning process can be further understood with the application of Kolb’s (1984) experiential learning theory. Kolb describes a four-stage cycle of initial exposure as a ‘concrete experience’. This is followed by an observational reflection of the experience by the learner(s), leading to analysis and formation of abstract concepts. Learners are then able to plan, develop and modify mental models in preparation for a repeat performance. This cycle closely mirrors the events that occur within a successful simulated experience. The simulation represents the ‘concrete experience’ and the actual ‘learning’ is provided by the subsequent debrief, where learners have the opportunity to reflect and analyse the events of the clinical encounter and make changes when returning to a new simulation and more importantly a ‘real life’ situation. This ongoing cycle is a ‘continuous process of goal-directed action and evaluation of the consequences of that action’.
The Debrief Process
The Pre-briefing Stage (Setting the Scene and Agreeing the Agenda)
Once you have decided that a debriefing is beneficial, you then need to plan the process. First, you need to ensure that the participants understand the process, are prepared for it and that both the environment and setting are appropriate. Second, who is going to facilitate the ‘debrief’? This can be more than one person, but the individuals need to plan the session together to ensure that all necessary areas are covered, without the facilitators dominating the discussions and to avoid repetition. You also need to be certain about who is being debriefed. Third, be sure of your objectives and the aspects of the experience needing to be covered. In the majority of team debriefs following a clinical simulation, the focus of the debriefing will be human factors and non-technical skills, which are discussed in detail in Chapters 6–8.
Sometimes a more thorough debrief of the technical aspects of the experience is appropriate. This will be dependent on multiple factors, including learning objectives, simulation participants and intervention location. When considering technical aspects ensure that you are prepared with up-to-date guidelines and recommendations to enable you to answer any questions or settle any disagreements accurately. Finally, you need to consider the debriefing model you are going to use.
Experiential learning requires active engagement (Chronister and Brown, 2012), meaning that in order to maximise the quality of the discussions during the debrief it is essential that those engaging in the process are equipped to do so. This necessitates securing both physical and emotional safety. Arafeh et al. (2010) support this by explaining that learners are prepared for the simulated experience by initially establishing their security.
It is important to appreciate and understand that participants may harbour fears and apprehensions surrounding the simulation and the debrief stages, particularly if they are new to the process. An awareness of the vulnerability of the participants is required (Fanning and Gaba, 2007) and it is important that the facilitator(s) create an atmosphere of trust and mutual appreciation. These fears may centre upon performance, knowledge gaps or potential error, and if not tackled may hinder the educational success of the intervention. Therefore, it is vital that ground rules about expected behaviour are agreed and that learning goals and aims are discussed. To maximise confidence in the process and minimise anxiety it is important to encourage openness and the sharing of information. This should take the form of a confidentiality agreement to which both confederate and facilitator agree, in effect ‘Chatham House Rules’. In addition, it is also important to enter into a period of orientation through an interactive tour of the simulation area and equipment combined with an illustration of the methodology. This period of familiarisation to the simulation environment is an opportunity to gain acceptance to the reality that the area is a recreation and ‘not real’. It is also an opportunity to request that the participants ‘suspend disbelief’ in order to maximise the experience. This is potentially more challenging ‘in situ’, although can be addressed in part by familiarity with the clinical environment. Our personal practice, where possible, would be to engage with the clinical area prior to the intervention and encourage participants to become acquainted with the team, the equipment and the methodology. This is particularly useful for those who are simulation-naïve, while also providing the simulation team with an opportunity for reconnaissance and cross-checks.
Debrief Delivery Stage
‘A debriefing is a time to reflect on and discover together what happened … and what it all means’ (Steinwachs, 1992). In healthcare education it has often been referred to as a ‘learning’ conversation and as mentioned above, according to educational theory, is stated as a time when the majority of the ‘learning’ occurs. To learn from a clinical exposure participants must be able to critically evaluate both the team’s performance and their own. Therefore, one of the primary aims of the debrief is to aid this process through facilitation. There has been much discussion in the literature about the levels of appropriate facilitation. Some individuals and teams debrief themselves and require little facilitation, but others need guiding through the process. Fanning and Gaba (2007) suggest considering the following factors when deciding the amount of facilitation required:
1. The objective of the experiential exercise
2. The complexity of the scenarios
3. The experience level of the participants as individuals or as a team
4. The familiarity of the participants with the simulation environment
5. Time available for the session
6. The role of simulation in the overall curriculum
7. Individual personalities and relationships, if any, between participants
The authors go on to discuss the role of the facilitator and the careful balance that needs to be sought between active involvement of the participants and them taking responsibility for their own learning and ensuring that important issues are addressed. The correct balance will result in maximal learning.
The initial stage of the debriefing process should essentially provide a chance for cathartic release, when participants can express any strong emotions they are feeling following the clinical or simulated experience. It is therefore critical to provide a safe and supportive environment for the participants to ensure this occurs freely. The facilitator should then guide the participants through the various stages of the debriefing, initially stating the ‘facts’ and then encouraging them to explore the thought processes and emotions around their clinical decision-making. This should include any performance gaps identified, while ensuring the objectives of the session are achieved.
While the human factors involved in team resource management are usually the main focus in the debriefing sessions, technical questions should be adequately answered and can provide an opportunity to review published guidelines. Alongside processing new learning, the experience from the simulation should be linked to ‘real life’ situations to put the learning into context.
In a nutshell, the ‘facilitated’ debrief should provide a safe environment for participants to air their views openly and honestly. The facilitator guides them through a reflective process, focusing on the performance rather than the performer, reviewing their mental models and introducing new ideas, while considering changes in behaviour or approach. The facilitator should encourage candidates to relate their learning to ‘real’ patients and ‘real’ situations, with each session culminating in some ‘take home messages’. The process should be neither judgemental nor non-judgemental, but a balance between the two. Rudolph et al. (2006) describe this as ‘debriefing with good judgement’.
Models of Debrief
Various models for debriefing have been described and there are many more that haven’t been formally published. The majority of models are based on the theories behind psychological debriefing, which is considered to have the following phases:
1. Initial phase (Introduction). This phase is when introductions occur, the purpose of the simulation is stated, objectives are set and ground rules are agreed. During this time a climate of trust must be achieved by assuring a safe, confidential and supportive environment. It is often referred to as the ‘Pre-brief’.
2. Fact phase – factual details of the experience are discussed.
3. Thought phase – exploring mental models and critical thinking behind decision-making.
4. Reaction or feeling phase – ‘how did that make you feel?’
5. Symptom phase – physical and psychological effects of the experience.
6. Teaching phase – opportunity to discuss guidelines or policies and introduce new concepts/learning.
7. Re-entry or wrap-up phase – summarise, answer questions, develop plans for future actions, take home messages.
The majority of models for debriefing are based on these phases. In practice, phases 2–5 and most notably 3–5 tend to blend together to allow for a more natural flow for the discussions.
Pendleton’s work is probably one of the most well-known models for feedback in medical education and is still utilised on many of the life support courses, but it has been heavily criticised for being too rigid and few would recommend its use for debriefing.
SHARP Model
The Imperial College of London describes a simple five-step debriefing tool, SHARP. These steps are subdivided into two phases; the first phase should occur before the simulation and is essentially the pre-brief, the second phase occurs after the simulation, fundamentally the debrief (Figure 4.1).
