What Is Debriefing?
The concept of debriefing after a challenging event has become commonplace in the health care simulation world, but debriefing as we describe it in this chapter includes a systematic discussion of any immersive event, real or simulated. We explore the debriefing process and its potential to spur reflection and affect learning across a broad spectrum of clinical activities and environments. Although simulations are especially appropriate for debriefing because they are planned exercises with known challenges and learning objectives, any clinical event can provide rich material for reflective learning. The skills described in this chapter can be used to help improve patient care and safety, enhance your own clinical expertise, and uncover systems issues in any environment.
For more than 20 years, we have worked to hone our skills in debriefing, and in this chapter we hope to introduce you to some of what we have learned. Although we will mention work by many others in health care and in other industries, this chapter—like much of the rest of this book—is largely a description of how the authors view and conduct debriefing. This is not intended to be a systematic review of the literature or an exhaustive description of all debriefing techniques. We will describe what we believe to be the most important concepts and issues and will concentrate on explaining our own approaches to debriefing.
The military originated the term “debriefing” to describe a process in which individuals systematically recount events after a mission to extract information and review lessons learned, whereas a “briefing” takes place as preparation before the mission. This meaning of debriefing was adopted by commercial aviation to describe postsimulation discussions. In 1990 our exploration of the aviation experience led us to adopt this postsimulation debriefing approach as the primary method of extracting the most learning out of simulations in anesthesia. This approach was then adopted widely in the rest of health care. Subsequently, the aviation industry produced training guides that delineated principles of debriefing. These sources are also of value to those working in health care. The debriefing practices we promulgated beginning in the early 1990s are consistent with subsequent aviation training guidance. ,
What Is the Role of Debriefing in Simulation-Based Learning in Health Care?
Under what circumstances, especially following a simulation activity, is a debriefing warranted? Some types of simulation and part-task training, especially those dealing with specific technical or psychomotor procedures, may incorporate sufficient guidance in the simulation device itself to make direct involvement by an instructor unnecessary. In certain circumstances, an instructor may be able to provide technical guidance and feedback without a formal debriefing. For some simulation activities, especially with early learners, other pedagogical techniques, such as having a “teacher in the room” to guide, advise, and teach during the simulation scenario, may be more appropriate than a postevent debriefing. However, for many simulation activities, especially as attendees gain clinical expertise, allowing the participants to perform their (simulated) clinical work uninterrupted is important. A detailed discussion of what transpired, after the fact, adds to the learning experience. In concert with a major expert in aviation debriefing in 2006, we wrote, “When it comes to reflecting on complex decisions and behaviors of professionals, complete with confrontation of ego, professional identity, judgment, motion, and culture, there will be no substitute for skilled human beings facilitating an in-depth conversation by their equally human peers.” This intuition is borne out by the empirical study by Savoldelli and colleagues, which found that participants failed to improve their nontechnical performance in complex scenarios if they were not debriefed in this reflective fashion.
Of course, not all postevent debriefings are the same. How they are conducted, and by whom, can have a significant effect on both the learning process and the learning climate. For example, in Line-Oriented Flight Training simulation exercises, how participants felt about the overall quality of the simulation experience correlated significantly with their perception of the skills of the debriefer. Participants in health care simulations share this sentiment, in which the skill of the facilitators is thought to be a key factor in the learning process and in the credibility of simulation-based learning courses. Health care simulation instructors feel even more strongly that debriefing is the most important part of realistic simulation training, that it is “crucial to the learning process,” and if “performed poorly, can actually harm the trainee.”
Debriefing Differs from Traditional Teaching
Not surprisingly, debriefing is considered by many instructors of crisis resource management (CRM)-oriented simulation training to be the most challenging skill to perfect. Even after 24 years, the most experienced of us are still learning to debrief. The teaching environment in simulation-based learning is very different from that of the traditional classroom, and is also different from that of real clinical work. In the classroom, learning objectives are firmly set, whereas in real-life clinical situations they are dictated by clinical events. Simulations lie somewhere in between. Although learning goals exist, they may change depending on participant needs, on how the scenario progresses, or on the issues that surface during the debriefing phase itself. Especially with more experienced participants, debriefers strive to be perceived less as experts, and more as guides for participants as they work through their own self-directed and group-directed learning processes. In a debriefing discussion, the instructor often poses a few questions or comments to trigger discussion. Often the ideal question to pose may be one that “self-perplexes”—that debriefers themselves cannot answer. Having started the discussion, debriefers may comment at suitable moments to redirect or refocus the conversation. Participants speak at considerable length, back and forth with each other, often without verbal input from the instructor. We encourage debriefers to use open-ended questions directed to the group as a whole rather than just to participants who have played the most active roles. The opinions of all group members are sought, and where possible, quiet individuals are drawn out. When participants direct questions at the debriefer, we encourage the instructor to reflect them back to the group rather than provide the “answer” directly.
Debriefing is different than providing “feedback.” Feedback most commonly implies observations and advice by the teacher about the level of performance of the learner versus a reference level of expected performance. Although feedback can be conducted in different ways, we often see it performed as a one-way process that requires little input from the learner. Debriefing may include feedback, but debriefing implies a more nuanced interactive conversation exploring how and why a particular sequence of events occurred, and what techniques or choices could have been used to change the process and outcome. In the language of Kolb’s experiential learning theory, debriefing provides the occasion for reflection as the middle component of learning, in the cycle that begins with doing, and ends with consolidation of knowledge and skill.
To maximize participant-led discussions, our approach encourages debriefers to be impartial whenever possible, and to avoid making personal judgment calls on performance (e.g., “you did that really well” or “you need to improve that”), even when the participants seek a judgment. We also dissuade participants from making similar calls, always stressing the critique of the “performance” rather than the “performer.”
We encourage debriefers and participants to develop a tolerance for ambiguity, to allow instructors to relinquish some control of the learning process, and to empower the participant to lead the way. Instead of talking, debriefers must learn to listen and observe, to be sensitive to nonverbal nuances and cues, and to interpret behavior so as to optimally encourage engagement and direct discussion.
On the other hand, debriefers should try not to get too distracted formulating the perfect statement or question. Fostering an engaged conversation is much more important than aiming for the most efficient or the most probing inquiries. Focusing on active listening rather than on optimal questioning is the best way to keep the conversation going. In total, all these elements can be quite a departure for many educators. Adapting their teaching style to the debriefing approach can initially be very challenging, but the increased participant engagement is rewarding in the long term.
General Features of the Debriefing Process
Although there are a number of structural elements common to most debriefing sessions, the exact characteristics or value for these elements will depend on the curriculum and session. The key elements of debriefing sessions typically include:
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The debriefer(s) (although the learners may sometimes act as their own debriefers )
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The goals and objectives of the debriefing
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The participants or learners to be debriefed
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The characteristic of the event itself (usually a simulation scenario) and its impact on the participants in the session
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The participants’ recollection of what transpired and the effects of hindsight bias
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The timing of the debriefing relative to the scenario, and the debriefing’s phases
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The physical environment of debriefing
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Use of audio-video recordings in debriefing
The Debriefer
Who should debrief? What is the optimal number of debriefers? Do debriefers need to be subject matter experts in the area targeted by the simulation scenario? The answers to these questions start with the simulation session’s learning objectives. If the main emphasis of the activity is on CRM or teamwork skills, an expert in these fields can debrief very effectively without being a clinical expert. If there is more than one debriefer, each may debrief within their skill set or area of expertise. Depending on the complexity of the scenarios and the seniority of the participant population, a clinical expert trained in debriefing may also be required to fully address clinical questions. For example, in the Maintenance of Certification (MOC) in anesthesia simulation course for board certified anesthesiologists undergoing their 10-year MOC cycle, there is a requirement that at least one instructor (presumably one who takes part in the debriefing) is a board-certified anesthesiologist.
Debriefers who debrief in pairs may complement each other, relying on implicit reading of the flow of the debriefing or on subtle signals to coordinate their efforts. Debriefing in pairs can improve the flow when one debriefer is struggling to engage the group. It also serves as a method for honing the skills of inexperienced debriefers. However, it requires skill and tact on the part of dual debriefers for it to work effectively, and logistics may dictate that the number of instructors be limited. Hence solo debriefing is common; it can be very effective, particularly if the debriefer is skilled at using a variety of debriefing techniques. Although we typically think of debriefers as coming from the faculty pool, it is possible, in certain instances, for participants who are given appropriate guidance to act as their own debriefers. , In multimodality simulations, where mannequin-based simulations also include standardized patient (SP) actors, the SPs may also contribute to the debriefing, either “in role” or as debriefers, offering a unique perspective. The debriefing process is not rigid, and it should grow and evolve within programs, depending on the availability of facilitators, their level of expertise and experience, and the needs of the participant population.
Debriefing through facilitation is more than simply “making the discussion easier.” Ideally, it is a guided pathway to meaningful discourse that will encourage learning and behavior change. The exact level of facilitation and the degree to which the facilitator is involved in the debriefing process can depend on a variety of elements, such as learning objectives and overall curricular goals, the experience level of participants, and their familiarity with the simulation environment. It may also vary with the complexity of the simulation, the setting in which the debriefing occurs, and even the time available for debriefing.
The aim is to encourage the majority of the discussion and dialogue to stem from participants, in which the debriefer interjects only as necessary to keep the discussion on track to achieve particular learning objectives. Effective debriefers encourage participants by actively listening, often using nonverbal encouragement (e.g., nodding), or echoing statements made by participants.
Debriefers should be aware of the learning objectives prescribed by the curriculum, and also recognize that the stated objectives may not be those of the participants. Participant-driven learning objectives arising as part of a deep discussion may often override the preestablished learning objectives when they have special meaning to the learners and are not inconsistent with the overall goals of the curriculum. Adult participants are particularly cognizant of the relevance and applicability of what they are being taught, and may become more engaged when discussing issues that are pertinent to their needs. On the other hand, they may become frustrated or disengaged if they are not given the opportunity to discuss the issues that are most important and relevant to them.
The terminology regarding levels or degrees of facilitation can be confusing. In some sources (especially Dismukes and colleagues , ), a “high level” of facilitation describes debriefings that show “little input” by the instructor, favoring encouragement of conversation as described earlier. Conversely, “low level” facilitation means “much” involvement by the instructor, even to the point of lecturing. Varying levels of instructor input are appropriate for different types of simulations, different participant populations, and learning needs.
The Participants
The role of participants in the debriefing process differs considerably from that of the learner in the traditional classroom setting. Instead of being passive recipients of information, debriefing demands that participants demonstrate an ability and willingness to critically reflect on and analyze their own performance. This process involves exploring not only what happened, but why, and what lessons can be learned to improve future performance.
Participants may be homogeneous, from a single discipline, or diverse, with hierarchical elements in the case of combined-team exercises. They may have varying levels of expertise both in their clinical domains and in their prior exposure to simulation activities. All of these elements will affect the extent of instructor guidance and the styles of debriefing employed. Sometimes participants who are longstanding coworkers can be more forthcoming when they already feel comfortable conversing with each other. Others prefer to be anonymous among participants they do not know, needing some time to get used to their co-participants before they fully open up. The debriefer needs to quickly evaluate the group dynamics and adapt the debriefing style and techniques accordingly.
The Goals and Objectives of the Debriefing
The goals and objectives may vary considerably depending on the setting, resources, participant population, and desired outcome. Debriefings of early learners may be more focused on achieving clarity of what transpired clinically and on the available management choices, with nontechnical skills having a lesser focus. As the experience of participants rises, the focus of debriefing often shifts to a greater emphasis of CRM principles and systems issues, with a secondary focus on the medical and technical specifics of the scenarios. Similarly, short debriefings following announced in situ simulations (e.g., mock codes) typically focus on discrete learning objectives, often addressing systems issues that are pertinent to the in situ environment. Debriefings following a scenario conducted for research are often intended primarily to extract more information about the decision making of participants rather than to enhance their learning.
Characteristics and Impact of the Simulation Scenario
Scenarios designed with clear debriefing aims in mind usually lead to more success in achieving learning objectives and goals. The complexity of scenarios should be tailored to the level of experience of participants and to the relevant teaching goals. Anesthesia crisis resource management (ACRM) scenarios challenge participants to make complex decisions and to formulate, adapt, and execute difficult diagnostic and treatment plans both as individuals and teams. Scenarios with such complexity allow a rich discussion of different aspects of the performance during the debriefing. The number of participants engaged simultaneously in the scenario will also affect the debriefing (e.g., a single participant, a stratified group of participants with one individual in the “hot seat,” or clinical care provided “by committee” of an entire group).
Simulation demands a flexible approach to teaching and learning, forging educational opportunities from diverse, and perhaps unplanned, events or experiences. Should a scenario fail catastrophically (e.g., as a result of a serious simulator glitch), it may be appropriate to abort it, acknowledge the failure, and either forego the debriefing or conduct a discussion about the scenario case that was planned. Alternatively, when malfunctions allow the scenario to proceed in a credible clinical fashion, the instructor may decide to continue and to use the events of the scenario to achieve an evolving educational opportunity. Simulation is like live theater: often “the show must go on.” Having a good sense of humor about such events is usually appreciated by the participants.
Scenarios that are challenging to the “psyche” of participants or that probe ethical decision making require special attention, both in their design and the nature of the debriefing process. , These scenarios may include those in which the simulated patient dies or those in which a more junior clinician is required to challenge the judgment of senior personnel.
Some scenarios involve significant interaction with “family members” or nonparticipant “colleagues” who are acting as the confederate of the instructor. How these confederate roles are handled is important. If a major confederate role is played by a nonparticipant faculty member (either from the simulation team or from the real world of clinical care), it risks confusing participants. They may be unsure, either in the simulation or during the debriefing, whether the confederate is speaking in their simulation role or in their real world role. In such instances, participants should be informed of the confederate’s status either ahead of the scenario (if that will not alter its impact) or prior to the debriefing. In either case, it should be clear during the debriefing from which role the individual was (during the scenario) or is (in the debriefing) speaking. The debriefing of scenarios that knowingly challenge the participants’ psyche is best facilitated by instructors with the experience, training, and skill to conduct an appropriately nuanced debriefing and to recognize and handle any adverse reactions from participants. Programs should be prepared to refer participants for professional counseling should the need arise.
Recollection and Hindsight Bias
Participants’ recollection of events fade and change, both during the scenario and after it concludes. Memory is imperfect and is affected by many factors. A very important factor in most debriefings is hindsight bias, introduced by already knowing the “outcome” of what transpired. The “I knew it all along” feeling of hindsight bias is very powerful and most people are prone to it even when advised of it or trained to handle it. To mitigate hindsight bias, it may be helpful to use debriefing techniques that explicitly consider all the diagnostic and treatment possibilities rather than concentrating solely on what actually transpired or what was actually wrong with the simulated patient. Using the video recording of the scenario may help clarify facts and events at various points, bypassing subjective recall. We instruct participants to “think out loud” during scenarios so that their thought processes can be captured on the recording. This provides a contemporaneous record of participants’ thinking and may help reduce hindsight bias during the debriefing.
Another way to counteract hindsight bias is by using scenarios that terminate before the underlying diagnosis or process becomes apparent. Participants will have genuine uncertainty as to what diagnoses or actions are best, even as they enter the debriefing. However, this may come at the cost of not letting them fully complete diagnostic and treatment steps, which itself may be frustrating. To counteract this frustration, one may consider affording participants the opportunity to practice a procedure or treatment strategy at the end of the debriefing session.
Timing and Phases of Debriefing
Debriefings often occur immediately after an exercise, but they can also be placed within a scenario, in the “pause and reflect” style of teaching. Debriefings can be conducted sequentially, with a quick initial debrief followed by more in-depth debriefings of certain skills targeted to particular individuals or groups. This sequential style may be suited to “unannounced” in situ simulations such as mock codes in a hospital where participants may need to quickly leave the site of simulation to return to care for real patients. Debriefings can also be conducted remotely in time, allowing a different perspective to be explored than would prevail immediately following an event.
The Introductory or Briefing Phase: To some extent, debriefing begins with the ground rules set in the introduction to a simulation course or in a briefing that immediately precedes a specific scenario. Instructors set the parameters for how simulations and debriefings are to be conducted. This includes rules of engagement, issues related to confidentiality, the recording and storage of data and its subsequent use, and the protection of participants’ privacy. The process for debriefing and the expected role of participants is explained. We, like others in the simulation community, give a high priority to creating a psychologically safe environment in which open and frank discussion of performance, clinical hierarchy, and systems-based concerns can be aired. Psychological safety—the individual’s feeling that the current environment is safe for interpersonal risk-taking and discussion—is an important ingredient of learning in groups. In health care, it is thought that such considerations optimize learning behavior and should ultimately facilitate improvements in patient safety. ,
In our programs, we usually explicitly state that we will collectively be “critiquing the performance, not the performer.” We encourage participants to initiate and sustain the discussion during debriefing, stressing the impact of their level of engagement on their learning. We empower them to help guide the debriefing process toward learning objectives that are meaningful to them.
Defusing Phase: Immediately after the scenario concludes, even during a short walk to a debriefing room, the participants usually start a defusing or cool-down phase. , They begin to release the tension of the simulation exercise, seek and give support to team members, and often begin a debriefing discussion among themselves. Observing participants in the defusing stage can provide material for debriefing and give insights into their behaviors and actions and the team structure and dynamics. The debriefer should control the length of this phase, allowing a period of emotional release but stopping the defusing process before the participants’ discussion goes too far into a haphazard analysis.
Recollection, Description, and Clarification Phase: Defusing is followed by a stage of recollection, description, and clarification of the simulation events. , The emotional impact of the experience can be explored individually or by the group as a whole. , , As in the defusing phase, at various points in this phase, the debriefer may need to intervene explicitly to prevent participants from “jumping ahead” prematurely in their recollection and discussion of the case. This mitigates hindsight bias, and allows a more structured discussion of key points. We may say, for example, “Hold on, let’s talk more fully about the current issue and we’ll get to the other one in a little while.” Debriefers need to learn how to exercise control to optimize the debriefing while not unduly interrupting meaningful conversation.
Generalization Phase: The third phase involves generalizing from the subjective experience of the case or scenario to a collective reflection and analysis of the issues and principles that apply to many cases. The debriefer guides the discussion, provides context as to how prior runs of the same scenario have revealed similar or different lessons, and may encourage participants to focus on approaches that can be applied to real patient care.
The Physical Environment for Debriefing
The physical environment in which debriefing takes place deserves careful consideration, especially because it can affect the degree to which participants are encouraged to engage in open discussion and reflection. For detailed or “long form” debriefings, it is usually ideal to have a dedicated debriefing room nearby, because excessive distance from the simulation exercise may lead to distraction and discourage cohesion. The layout of furniture in the room can enhance or detract from open discourse. Ideally, facilitators and participants should sit around one table (or in a circle without a table) so as to include everyone at an equal standing in the discussion. Participants who are not at the table can feel excluded from the discussion and more easily distracted. When there is more than one debriefer present, debriefers should consider where they sit relative to participants and to each other. Co-debriefers may wish to sit opposite each other so that they can better see each others’ nonverbal cues.
Debriefing outside a dedicated debriefing room, such as after in situ simulations, can provide some challenges; however, regardless of the constraints of the environment, there is always a need to create a sense of respect and community among participants and instructors. Sometimes it can be helpful to have the group step away from the bedside to create a suitable environment for debriefing. When debriefing in a clinical work area, it may be especially important to ensure a safe debriefing environment and to assure participants that the goals are education, training, and systems improvement, geared toward optimizing patient safety. Safety also dictates that special care be taken to ensure that no equipment or medications that are unfit for clinical use remain in the clinical environment.
Debriefing at the site of simulation also brings some opportunities. If debriefing a systems-based issue, being at the clinical site can help the debriefer to explore the role of equipment or patient care processes on the success of clinical work. It may then allow participants to interact with the environment and to briefly recreate elements of the simulation within the debriefing session. Thus, even when a dedicated debriefing room is available, debriefers may sometimes, elect to debrief at the site of the simulation exercise, or they may do it to add variety to a day.
Use of Video in Debriefing
Following the lead of aviation CRM programs, since the very first ACRM courses in 1990, we have made it a regular practice to record both the audio and video of simulation scenarios. In the early years, we tended to replay the entire video during the debriefing, pausing it periodically to allow discussion. Ultimately we determined that this was too time consuming and redundant, and inhibited good discussion. As we have become more experienced in simulation, we still record our simulations and debriefings, but we use much less video playback for debriefing purposes and we use it more strategically. Excessive use of video playback can be distracting. Our philosophy is that the goal of the debriefing is to have the group talking about interesting and useful issues and principles, and therefore the use of video should be to enhance that process rather than to be an end in itself. As video systems in simulation centers have become more complex, there is also a growing risk of system failures, or that instructors will not be skilled in using the system. If there are problems with the video playback that cannot be resolved very quickly, it is best to avoid it entirely instead of continuing to struggle and thereby preclude or disrupt a useful discussion.
Playback segments are best selected and explicitly framed by scenario events, points of use of specific CRM principles, or diagnostic or treatment decision points. Typical examples of selections for viewing in the debriefing might be: when a clinical event is first detected or recognized, when the first responder clinician is being briefed by the primary clinician, or when critical communication is taking place between the anesthesia professional(s) and the surgical team. When video is used, the debriefers should clarify what they are illustrating or what they wish the group to observe or comment on.
Clearly, the use of video replay is not a prerequisite for a successful debriefing session. , , In fact, a study by Savoldelli and colleagues showed that, although debriefing enhanced learning, there was no additional value added by the instructors’ use of video replay. It is likely that the strategic use of video can add value to debriefing, but in what context and format remains to be elucidated.
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