As a debriefing technique, advocacy inquiry (AI) attempts to uncover the “frame” or rationale behind a participant’s behavior [7–9]. 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 [7–9]. 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.

The plus-delta technique is another established technique where a facilitator guides a team to verbally produce two lists [4–6]. 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 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.

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.

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 [22–29], 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 [33–36].