The Art of Debriefing

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The Art of Debriefing

• HPSN 07
• Hal Doerr, MD
• Judy Johnson-Russell Ed.D., RN

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Simulation Learning Pyrmid
Transference
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Adult Learning Principles

• Andragogy

Pedagogy
Snoop-Doggie
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Adult Learning Principles

• Andragogy

Pedagogy
Sammy doggy
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Adult Learning Malcolm KnowlesAndragogy

• Adult Learners Are autonomous and self directed
• Bring experience
• Expect to influence How they are educated
• Expect to influence How learning will be
  evaluated
• Active participation is encouraged
• Need to see the possible applications
• Expect their responses to be acted upon

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Adult Learning 4 Critical Elements

• Motivation
• Reinforcement
• Retention
• Transference

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Adult Learning4 Critical Elements

• Motivation
• Set the Tone of the Simulation
• Set the Level of
• Concern
• Tension / Importance
• Appropriate Level of Difficulty

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Adult Learning4 Critical Elements

• Reinforcement
• Positive Reinforcement (Create)
• Good Behaviors / Attitudes
• New Learners
• Novel Approaches
• Negative Reinforcement (Extinction)
• Bad Behaviors / Attitudes
• Experienced Learners
• New and Old Approaches

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Adult Learning4 Critical Elements

• Retention
• Learners must
• See a Meaning or Purpose to the material
• Have the ability to Interpret and Apply the
  material
• Ability to assign the correct degree of
  Importance to the material
• Retention Degree of original Learning Amount
  of Practice

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Adult Learning4 Critical Elements

• Transference-
• The ability to take information from the
  session and apply it to a new or novel
  situation.
• Positive Transference-
• Use of Behavior taught in the
  session.
• Negative Transference
• Learners Do not do what they are told not to
  Positive outcome

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Experimental Learning Theory---Kolb

• First proposed a four stage learning process 1995
• The learner can begin at any point in this cycle
• There is no limit to the amount of cycles you can
  make in a given learning situation
• Kolb states, that without reflection one will
  continue to repeat their mistakes
• Assertion
• Without Reflection Without Debriefing

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Experimental Learning Theory---Kolb
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SimulationRules of EngagementCode of Conduct

• Fly as you Sim- Sim as you Fly
• Patient is real
• No torpedoes
• Support only when requested
• Never discuss performance outside the simulation

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DebriefingRules of Engagement 1Code of Conduct

• Follow Initial Goals and Objectives
• Maintain Privacy
• Follow Adult learning Principals
• Have a backup plan (In case of a change in the
  participants behavior or actions that need to be
  addressed)
• Be open to changes in the Sim

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DebriefingHistory

• Alaskan Tribes
• Pyramids
• Quakers
• Gandhi
• Meeting Facilitation (1960-1970)
• Learning / Awareness Facilitators (1960s)
• Learning became a dialogue not a wrote
  process-Sam Kaner-Organizational Psychologist)

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Goals of Debriefing

• Recognize and release emotions built up during
  simulation (Fritzsche, Leonard, Boscia,
  Anderson, 2004).
• Safe place to express feelings
• Mistakes part of learning process (Henneman
  Cunningham, 2005).

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Goals of Debriefing

• Reinforce Objectives of Simulated Clinical
  Experience (SCE)
• Students often have a limited picture of what
  happened while involved in simulation while
  involved, they observe only those parts their
  position allows them to. (Peters and Vissers,
  2004)
• Assists in learning those things they missed
  while engaged in the SCE.

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Goals of Debriefing

• Student questions can be answered, student
  thinking can be clarified, teaching points can be
  emphasized (Fritzsche, Leonard, Boscia,
  Anderson, 2004 Jeffries, 2005).
• Published/standardized guidelines can be reviewed
  (Owen Follows, 2006).

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Goals of Debriefing

• Clarify Information
• Possible for students to manipulate the data in
  such a way that they distort it and make it fit
  into their previous learning.
• Through the debriefing process, faculty can
  insure that new learning is processed correctly
  (Chiodo Flaim, 1993).
• Connect theory to practice

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Goals of Debriefing

• Enhance Critical Thinking and Problem Solving
• Advantageous to compare different perspectives
  and a joint analysis. This increases student
  understanding (Peters Vissers, 2004).
• Safe place to discuss without constraints of time
  (Mort Donahue, 2004) and pressure of being in
  the simulated clinical experience
• Identify resources (IOM recommendation)
• Encourages Collaboration and Communication

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Goals of Debriefing

• Reflective learning (Mort Donahue, 2004).
• Reflection should relate to objectives
• Self-assessment
• Individually what do they need to work on?
• Feedback from peers
• (Henneman Cunningham, 2005
• Focus on performance, not performer

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Goals of Debriefing

• Link to the Real World
• Link what has been learned in simulated setting
  to real world (Chiodo Flaim, 1993 Fritzsche,
  Leonard, Boscia, Anderson, 2004 Peter
  Vissers, 2004).
• Acknowledge the unreality, link to real patients,
  real situations

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Ways to Debrief

• Number involved, participants and observers
• Separate, together
• Verbal, Written, Presentations,
• Prevent peers not involved from being critical
  and embarrassing those involved.
• If with participants and observers, need ground
  rules to make it a safe learning environment.
• Time available
• Video available
• Number of Faculty
• Availability of Facilities

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Professional Learning Environment
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Debriefing with Video

• Students must know in advance that they are being
  videotaped (Hravnak, Tuite, Baldisseri, 2005),
  how it will be used and when it will be erased
• Signed permissions (Scherer, Bruce, Graves,
  Erdley, 2003).
• Should erase tape after the debriefing (Hravnak,
  Tuite, Baldisseri, 2005).
• If kept for viewing by others, permission needs
  to be provided by students (Hravnak, Tuite,
  Baldisseri, 2005).

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Debriefing with Video

• Should be used with faculty led
  discussion/debriefing.
• Students and faculty review the videotape and
  collaboratively critique the students decision
  making and the outcomes (Hravnak, Tuite,
  Baldisseri, 2005).
• Provides psychomotor and visual learning, plus
  reflection, helps students increase competence
  (Graling Rusynko, 2004).

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Debriefing with Video

• Reminds students of specifics of SCE events.
• Event management and decision making at key
  crisis points can be discussed.
• Counter
• More appropriate actions can be suggested and
  theory to support the actions taken or not taken
  can be discussed. (Hravnak, Tuite, Baldisseri,
  2005)

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• Metivision makes it easy to debrief with video
• It captures and records your simulation sessions
• It integrates with current METI simulators

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• Tag a moment for instant return
• Mark a situational event
• Flag for review
• Annotate points in time
• Text and Audio notes
• Synchronized across the data
• Physiological, audio, and video feeds

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Debriefing RolesFacilitatorActuate self
discovery

• Facilitator a content neutral party, enables
  groups to work more effectively, learning or
  dialogue guide
• Facilitative Leader Aware of group and
  orgizational dynamics, creates processes to
  enable group members to more fully utilize their
  potentials
• Facilitative Individual -Team player, assists
  others

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Debriefing Facilitation ProcessStraus and Kaner

• Content Neutrality- Not having a position or
  stake in the outcome
• Process Neutrality Not advocating for processes
  such as brainstorming
• Facilitator- Content neutral and a process
  advocate, to balance participation and establish
  a safe psychological space for all to participate
  

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Debriefing RolesInstructor

• Socratic method
• Roberts Rules of Order
• CRM Principles
• Pharmacology
• Physiology
• Pathophysiology

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Facilitative Instructor
Instructor
Facilitator
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Debriefing Techniques

• Confrontational
• Content neutral
• Content specific
• Instructor driven
• Facilitator driven
• Action Debrief
• Critical Event Action Debriefing

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Debriefing Techniques

• Listen to the participants
• Make them part of the process
• Keep their attention to the process
• Allow for self direction

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Debriefing Techniques

• Positive reinforcement should begin each session
• Summarize each session
• Give direction for improvement
• Facilitate group direction for change

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Process of Debriefing

• Introduction
• Personal Reactions
• Discussion of Events
• Summary

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Introduction

• Prepares students to actively analyze and
  evaluate self and simulation activities.
• Communicate expectations
• Describe faculty role
• Facilitation vs evaluator
• Confidentiality
• Signed statement
• Safe environment to express feelings and ask
  questions
• Review objectives of the SCE

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Personal Reactions

• Students who have the opportunity to explore and
  deal with the feelings they experienced during
  simulation will be better prepared to deal with
  them in real clinical situations (Henneman,
  Cunningham, 2005)
• Begin with open-ended questions and use
  reflective responses to their statements
• Their responses can guide the discussion of
  events
• Ensure that all in small groups have the
  opportunity to respond

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Discussion of Events

• Encourage students to continually analyze the
  events in depth and their feelings and reactions
  to them.
• Students learn and remember more when they
  participate actively and make their own analyses
  (Duvall Wicklund, 1972).
• How familiar were you with the patients
  condition, treatments, and complications prior to
  the SCE?

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Discussion of Events

• What happened?
• What did they do as a team or individually?
• What was the outcome?
• What would they do differently next time,
  individually, as a team?
• What additional information, knowledge, skills,
  etc. do they think were/are needed in the
  situation, for the future?

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Discussion of Events

• View videotape whenever appropriate
• Or continue with questions from the METI PNCI
  Debriefing Guide.
• Question errors in judgment as in complacency
  with abnormal vital signs or vigilance errors as
  in the failure to attend to changing status.
• Ask about communication with the patient, family
  members, team members.
• Discuss errors with protocols/guidelines

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Discussion of Events

• Have them give specific examples of where they
  prioritized the needs of he patient effectively
• Ask if there were any techniques, interventions,
  or medications they were not familiar with.
• Ask what did they learn new from the SCE.
• Have them give example of information they
  received in class or their readings that became
  clearer to them during the SCE.
• Ask what individually and as a group they feel
  they need to work on.

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Summary

• Goal is to assist the students in looking at the
  overall experience. What they did, what they
  learned, what they have said they want to work
  on.
• Could be done by faculty or by asking open-ended
  questions of the students
• End on a positive note
• In summary, these are the things you identified
  as going well.

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Summary

• These are the things you told me you need to work
  on.
• The take home points include.
• I saw improvement in these areas.
• Thank the students for participating in both the
  SCE and debriefing
• Written Evaluation

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Questions
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References/Additional Readings

• Anderson, J. (2005). Debriefing worksheet.
  Unpublished.
• Anderson, J., Cox, S. (n.d.). Strategies for
  successful debriefing Presentation.
• Center for Medical Simulation. (2004, 2005).
  Institute for Medical Simulation comprehensive
  workshop. Author.
• Chiodo, J. L., Flaim, M. L. (1993). The link
  between computer simulations and
• social studies learning Debriefing.
  Social Studies, 84(3), 119-121.
• Dismukes, R. K., Gaba, D. M., Howard, S. K.
  (2006). So many roads Facilitated
• debriefing in healthcare. Simulation in
  Healthcare, 1(1), 23-25.
• Duvall, S., Wicklund, R. A. (1972). A theory of
  objective self awareness. New York,
• NY Academic Press.
• Fritzsche, D. J., Leonard, N. H., Boscia, M. W.,
  Anderson, P. H. (2004). Simulation
• debriefing procedures. Developments in
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• Learning, 31, 337-338.
• Graling, P., Rusynko, B. (2004). Kicking it up
  a notch- successful teaching
• techniques. AORN Journal, 80(3),
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• Haskvitz, L. M., Koop, E. C. (2004). Students
  struggling in clinical? A new role for
• the patient simulator. Journal of
  Nursing Education, 43(4), 181-184.
• Henneman, E. A., Cunningham, H. (2005). Using
  clinical simulation to teach patient
• safety in an acute/critical care
  nursing course. Nurse Educator, 30(4), 172-177
  Hravnak, M., Tuite, P., Baldisseri, M. (2005).
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• practitioner and clinical nurse
  specialist education Invasive procedure training

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References/Additional Readings

• Jeffries, P. R. (2005). A framework for
  designing, implementing, and evaluating
• simulations used as teaching strategies in
  nursing. Nursing Education
• Perspectives, 26(2), 96-103.
• Knowles, M. (1984). Andragogy in action. San
  Francisco Jossey-Bass.
• Mort, T. C., Donahue, S. P. (2004). Debriefing
  The basics. In W. F. Dunn (Ed.),
• Simulators in critical care and beyond (pp.
  76-83). Des Plaines, IL Society of
• Critical Care Medicine.
• Owen, H., Follows. V. (2006). Really good
  stuff GREAT simulation debriefing.
• Medical Education, 40(5), 488-489.
• Peters, V. A. M., Vissers, A. A. N. (2004). A
  simple classification model for
• debriefing simulation games. Simulation
  Gaming, 35(1), 70-84.
• Rall, M., Manser, T., Howard, S. K. (2000). Key
  elements of debriefing for simulator
• training. European Journal of
  Anaesthesiology, 17, 515-526.
• Rhodes, M. L., Curran, C. (2005). Use of the
  human patient simulator to teach
• clinical judgment skills in a baccalaureate
  nursing program. Computers,
• Informatics, Nursing, 23(5), 256-262.
• Rudolph, J. W., Simon, R., Dufresne, R. L.,
  Raemer, D. B. (2006). There's no such
• thing as "nonjudgmental" debriefing A
  theory and method for debriefing with
• good judgment. Simulation in Healthcare,
  1(1), 49-55.