Constructive Debriefing for Trauma Team Education


Phase

Description

Reaction

• Identify initial thoughts and feelings of participants

• Define learning objectives that are important to participants

• Emotional washout, unwrap mental mindset of participants

• Facilitators track topics and plan how to address them

Description

• Serves to establish a shared understanding of the case

• Solicit a brief summary of the case from a medical point of view and main issues

• May be abbreviated if team members had clear shared understanding of the underlying diagnosis and key issues

Analysis

• Facilitators use various techniques to guide discussion and address learning and performance gaps

• Integrate selected topics raised by participants

• Multiple potential approaches

   – Debriefer prompts plus-delta list generation

   – Debriefer gives performance feedback

   – Debriefer facilitates a discussion using advocacy inquiry

• Close performance gaps through discussion and/or teaching

Summary

• Allows learners to state take-home messages and how lessons learned apply to real-life clinical practice

• Instructor may add final comments to augment essential elements



The reaction phase allows the facilitator to identify the initial thoughts and feelings of the participants and, ultimately, define learning objectives that are most important to the participants [4, 69]. In this phase, the facilitator asks open-ended questions to provide participants the opportunity to vent their initial emotions related to the simulation, which may be feelings of frustration, fear, angst, confusion, appreciation, or elation over the event that has just taken place. Through this process, participants will also provide valuable information on their initial thoughts around the perceived care of the patient (both positive and negative). This step is vital to unwrapping the mental mindset of the participants (especially the emotional ones). If steps are not taken to allow the team members to share these emotions, they will be less likely to effectively reflect on their previous actions and, hence, unable to fully engage in interactive discussion during the remainder of the debriefing. Their initial thoughts are also key indicators of the areas that the participants want to review during the debriefing. Facilitators should carefully track these topics as they arise during the reaction phase and actively plan how and when they will address them during the analysis portion of the debriefing. As specific analysis and discussion of issues does not typically occur during this phase of the debriefing, the facilitator should consider summarizing the issues that have been brought forth by participants before proceeding to the next phase of debriefing.

The key purpose of the descriptive phase is to ensure that all team members have a shared collective understanding of the main details of the case, including the primary diagnosis and main clinical issues [21]. The facilitator typically asks one member of the team to summarize these details briefly in 1–2 sentences, followed by confirmation from other team members. In some cases, there are differing perspectives of the primary diagnosis or core issues. These should be clarified by the facilitator and/or the group before proceeding with analysis of specific behaviors. Failure to do so at this point in the debriefing may lead to confusion and/or misperceptions among some or all of the participants, thus increasing the risk of dissatisfaction or disengagement with the simulation debriefing at hand [21].

The bulk of debriefing is performed in the analysis phase [4, 69]. During this phase of debriefing, facilitators use various techniques to guide the team members toward identifying both positive and negative actions, as well as better understanding the rationale behind those actions and behaviors. By managing the flow and time available for discussion, the facilitator guides the group through issues that have been brought forth by participants while also covering the predefined learning objectives of the simulation scenario. Through reflective learning and feedback, the facilitator is able to promote the acquisition of new knowledge, skills, and attitudes, with the eventual goal of improving both individual and team performance in real patient care.

Once all of the performance issues have been identified, the final phase of debriefing typically involves a summary phase [4, 69, 21]. During this phase, a summary of the key take-home points is either provided directly by the facilitator or brought up and reviewed by the team. This ensures that the main learning points from the case are reinforced, with the hopes of positively influencing change in provider behavior for future trauma cases.



Debriefing Method


Several formats exist allowing the facilitator options when conducting the analysis portion of the debriefing. The method selected by the facilitator is most likely based on various factors: the time allotted for the debriefing event, the rationale evident behind the teams’ actions during the scenario or event, the facilitators’ comfort with using the selected method, the type of learning objective, and the level of insight/experience of the participants. The methods that will be reviewed here include advocacy inquiry (Debriefing with Good Judgement) [69], Plus Delta [4, 5], Directive Feedback, and Blended Methods of Debriefing [21].


Advocacy Inquiry


As a debriefing technique, advocacy inquiry (AI) attempts to uncover the “frame” or rationale behind a participant’s behavior [79]. By uncovering the “frame” of an action, the facilitator better understands how to provide feedback for an action. This technique is particularly useful when the rationale behind an action is not clear or immediately apparent (to the facilitator or other team members). AI uses a series of factual statements to uncover the positive and negative performance issues without making assumptions as to the driving rationale behind these actions. The first statement is a clear, concise, and specific observation about an action or behavior that was seen or heard. The second is a short statement of appreciation or concern, reflecting the facilitator’s point of view related the issue at hand. The third statement then asks the individual or team to share their point of view related to the topic at hand (Table 36.2). The responses from team member(s) will then guide further discussion from the team around the topic area, with a goal of consolidating positive performance and/or improving negative performance [79]. By promoting reflection on previous actions in this manner, the facilitator can effectively engage learners in discussion and even have insightful teams address performance issues and answer questions on their own. Although AI is a highly powerful method when done appropriately by a skilled facilitator, it often takes much time to practice and master this technique. That being said, facilitators should consider practicing this technique in lower-stakes learning environments before using it in environments where patient and/or learner safety are at higher risk.


Table 36.2
Advocacy inquiry [79]

























Step

Possible statements/phrases

Observation

I noticed that…

I saw that…

Facilitator point of view

At the time I was thinking…

I was wondering…

Learner point of view

What were your thoughts at the time?

How did you see it?


Plus Delta


The plus-delta technique is another established technique where a facilitator guides a team to verbally produce two lists [46]. One list is the “plus”; the items that the team felt went particularly well during a case or simulation scenario. The second list is the “delta”; the items that the team felt could be improved upon for future performance. The advantages of this technique are that it is quick to learn and use and rapidly establishes a list of issues to frame further discussion. It is a particularly effective technique when there is very little time for debriefing [21]. Once the list of items are generated, specific issues may still require discussion, or at a minimum, the facilitator should provide some teaching to emphasize key take-home messages. The main disadvantage of the plus-delta method is that unless the individual items are further discussed in a reflective manner, the facilitator runs the risk of making inaccurate assumptions related to the underlying rationale driving specific actions and subsequently delivering the wrong teaching point [21]. For example, in a trauma resuscitation scenario, a nurse participant may comment that the team struggled executing the severe head injury protocol in a timely fashion. If the instructor makes the wrong assumption and assumes there was a knowledge deficit and subsequently starts teaching the severe head injury protocol, he/she may be missing out on the other potential causes for this performance deficit (e.g., errors in teamwork and communication).


Directive Feedback


Directive feedback is another technique when the facilitator provides teaching around a specific behavior or action. In its purest form, directive feedback is one directional (i.e., from teacher to learner) and does not involve discussion or reflective learning. This method is most suitable when the time available for debriefing is short, when the rationale behind a specific performance issue is clear and self-evident (to the facilitator and the group), or if the learners are inexperienced and/or have poor insight. This technique is particularly useful for clinical and technical skills, review of established guidelines or algorithms, and positive behaviors that one may want to reinforce. Similar to the plus-delta method, the main disadvantage is that the presumed rationale may be incorrect, with the consequence that the feedback provided targets the wrong objective.


Blended Methods


Experienced facilitators using the techniques described above have discovered that the use of one single debriefing method in isolation may not be optimally effective for all debriefing and learning environments. As such, some experts have advocated for a blended approach to debriefing while using various methods within a single debriefing event [21]. This allows for some flexibility based on the time allotted to debriefing, while still allowing the facilitator the ability to further uncover the rationale behind certain behaviors when there is uncertainty [21]. The blended approach allows for a more precise match of the specific learning needs of a team with the goals of the educator and should allow for more precise feedback in consolidating positive performance and/or improving negative performance.



Debriefing Real Trauma Teams



Advantages of Post-trauma Debriefing


Simulation provides fertile grounds for practice of effective resuscitation of critically ill patients and debriefing-generated learning on team process. Yet despite the growing evidence of the positive role of debriefing after surgical, anesthetic, or critical care-based simulation events [2229], translating debriefing practice from the simulation setting to real-life events has been a challenge.

The concept of team-based debriefing after stressful events developed out of an intention to integrate profound personal experiences on the personal, emotional, and group level. Debriefing in healthcare moved into the spotlight in 1983, when Mitchell described a formal technique targeted toward emergency services and disaster response teams which aimed to protect and support the group exposed to a critical incident by minimizing the development of abnormal stress responses [30]. Originating as an early psychological intervention after critical incidents associated with psychological stress and trauma, the intention of debriefing has expanded and evolved with a focus on improvement of team process by way of an educational intervention.

Debriefing is becoming recognized as an increasingly important procedure in medical team training, although the literature on debriefing in-hospital trauma teams is sparse. Anecdotally, healthcare providers perceive a need for debriefing in the acute care setting. Individuals who have attended debriefing often rate the experience as “valuable,” “helpful,” and a “morale maintenance” intervention [31, 32]. As a performance enhancement tool, debriefing is beginning to receive significant attention from major international organizations in resuscitation such as the American Heart Association and International Liaison Committee on Resuscitation; in fact, they are endorsing debriefing for events such as cardiac arrest and identifying its impact on future performance and actual patient outcomes as an important area of research [3336].

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Oct 28, 2016 | Posted by in CRITICAL CARE | Comments Off on Constructive Debriefing for Trauma Team Education

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