geoffrey t. miller assistant professor, school of health sciences
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The Art and Science of Debriefing. - PowerPoint PPT PresentationTRANSCRIPT
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Geoffrey T. MillerAssistant Professor, School of Health
SciencesDirector Simulation, Technology and
ResearchSentara Center for Simulation and
Immersive LearningEastern Virginia Medical School
The Art and Science ofDebriefing
Bottom line, up front…
Debriefing is an art form…
One which is honed through
repeated practice, and experience…
There are many approaches and techniques…
And very few absolute rules
Sessions aims
Identify the goals of debriefing.Discuss the elements of debriefing that improve outcomes.Identify various approaches to debriefing.Discuss the process of debriefing.
ARE YOU HAPPY
?
NO
YES
CHANGE SOMETHI
NG
DO YOU WANT TO BE
HAPPY?
KEEP DOING
WHATEVER YOU’RE
DOING
YES
NO
Human processing in action…
Human processingNatural order of human
processing
Experience an event
Reflect on it
Discuss it with others
Learn & modify
behaviors based on the experience
Why feedback/debriefing matters…
A = Education B = Things you know
A
B
C = Things you know you don’t know
A
C
D = Things you don’t know, you don’t know
A
D
Feedback…Debriefing…
isn’t it all just the same thing?
Feedback
Feedback comprises a wide array of informational inputs, which may occur prior to, during, and after an experience
Feedback is the most important feature of simulation-based learning
Knowledge of performance results - key to learningAppears to slow the decay of acquired skillsAllows for self-assessment
Issenberg SB,McGaghie WC, Petrusa ER, Gordon D, Scalese RJ (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher 27(1): 10–28.
Feedback sources
Pre-briefings, instructions, in-case sources, debriefings, peers(team members), log files [manikin, computer, etc], standardized checklists, rating forms, evaluators (faculty, peer, patient), recordings (video)…
The KEY is to use multiple sources of feedback… share them with the learner
Develop a plan for feedback that supports the individual and/or team learning goals
Debriefing
• A deliberative, learner-centric process designed to standardize the instructor/student post-event interaction to assist learners in thinking about:• What they did, • When they did it, • How they did it, • Why they did it and • How they can improve.
Factors influencing debriefing
Objective of the experiential exerciseComplexity of the scenarioExperience level of participants Experience level of participants with simulation environmentTime available for the sessionThe role of the simulation in the overall curriculumIndividual personalities and relationships, if any, between the participants
Debriefing myths… and realities
Debriefing myths…
“There is a highly defined process or method for
conducting learner debriefing”
Realities…
“there are surprisingly few papers in the peer-reviewed
literature to illustrate how to debrief, how to teach or
learn to debrief, what methods of debriefing exist and
how effective they are at achieving learning objectives
and goals”
Fanning, RM, Gaba, DM. The Role of Debriefing in Simulation-Based Learning. Simulation in Healthcare. Vol. 2, No. 1, Spring 2007.
Debriefing myths…
“The most effective facilitation is achieved when the
learners or participants do all of the talking…
not the instructor”
Realities…
Some learners or learner groups may lack an adequate
understanding of the event and it’s elements,
or posses enough prior learning and experience
to effectively reflect and learn.
Debriefing myths…
“Debriefings should always be conducted
in a separate space or environment”
Debriefing myths…
“Debriefings should always be held
after the simulation ”
Realities…
“in certain circumstances (teaching a technical skill,
fatal errors, or seriously flawed behaviors), debriefing
may need to occur during the simulation (AKA: in-
scenario debriefing)”
Debriefing considerations
The ultimate failure of debriefing
“Learners are left with the mistaken impression that they are doing just
fine”
“Ignorance more frequently begets confidence than does knowledge”
Charles Darwin – The Descent of Man (1871)
Identifying & closing the gaps
Performed well
Performed well
Performed poor
Performed poor
Feels good
Feels bad
Feels poor
Feels good
GAP
Observable performance Performance perception
KnowledgeSkill
Behavioral
Simulation-debriefing relationship
Activated
Inactivated
PleasantUnpleasant
ExcitedAlertElated Happy
BoredSadFatiguedDepressed
RelaxedSereneContentCalm
Simulation
StressedUpsetNervousTense
Debriefing
Coaching, prompting & cueing
CoachingDirecting, instructing and training a person or group of people, with the aim to achieve some goal or develop specific skills
PromptingTo move to action
CueingGiving verbal or non-verbal triggers/clues for an action to be carried out at a specific time
Instruction
Facilitation
Debriefing ‘Dose’
Learner Expertise
Debr
iefin
g Am
ount
/Tim
e
Novice Expert
“Debriefing Amount / Time will decrease with higher learner expertise, It will not reach zero”
Lots of debriefing modesPrivate bedside debrief by facilitator immediately post scenario
Private ‘debriefing room’ debrief by facilitator immediately post-scenario
Debrief by peers outside of simulation suite
Self-guided reflection of video performance
Prep Prep Debrief
Sim Change
Sim Sim
Debrief
Debrief
Prep
Change
Change
Ericsson, KA. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic Med. 79(10 Supplement):S70-81.
Ericsson’s Model of Deliberate Practice:
“Practice does not make perfect… practice makes permanent”
Feedback, debriefing & deliberate practice
Important debriefing points/skills
Be genuine and student centricAsk open not closed ended questions:
DON’T- Did you have a good experience?DO- Tell me about your experience.
Use pauses and silences to elicit feedbackUse probing inquiry to gain deeper understanding
Perspective on use of video
Use if necessary; typically to observe specific events or processesHave participants compare their memory with the recording- “Tell me what happened”Peer input can be inappropriate- facilitator needs to guide the discussion into positive channel
Debriefing Models
Structured & supported debriefing (SSD)
Developed in collaboration with American Heart Association
Definition of ‘structured and supported’Structured elements include three specific debriefing phases with related goals, actions, and time estimates. Supported elements include both interpersonal support as well as use of protocols, algorithms, and best evidence to inform debriefing statements/questions
Other considerationsSimple, can be learned rapidly, scalable, validated by practice
Adapted from: O’Donnell, J.M., Rodgers, D.L., Lee, W, W., Edelson, D. P., Haag, J., Hamilton, M. F., Hoadley, T., McCullough, A., Meeks, R., (2009), Structured and Supported Debriefing [Computer Software]. American Heart Association, Dallas, TX.
GAS Model
Goal:Listen to participants to understand what they think & how they feelGGATHER 25%
Actions:Request narrative from team leader
Request clarifying or supplemental information from team
Sample Questions:All: “How do you feel?”
Team Leader: “Can you tell us what happened?”
Team members: “Can you add to the account?”
GAS Model
Goal:Facilitate reflection on & analysis of actions
AANALYZE 50%
Actions:Review accurate record of events
Report observations (correct & incorrect steps)
Reveal participants’ thinking processes
Reflect on performance
Assure continuous focus on session objectives
Sample Questions:“Tell me more about…”
“What were you thinking when…”
“I understand, however, tell me about “X” aspect of the scenario…”
“Let’s refocus… what’s important is not who is right but what is right for the patient…”
GAS Model
Goal:Facilitate identification & review of lessons learned
SSUMMARI ZE
25%
Actions:Participants identify positive aspects of team or individual behaviors & behaviors that require change
Summary of comments or statements
Sample Questions:“List two actions or events that you felt were effective or well done”
“Describe two areas that you think you/team need to work on…”
Plus- Delta
A student-centric approach simulation debriefing using a 2 X 2 matrix. Designed to rapidly gain participant feedback on both instructor and participant performance
Debriefing With ‘Good Judgment’
Trainee ‘Frames’ Approach Frames to Actions
to ResultsA frame is the internal trainee environmentPerceptions, knowledge, assumptions, feelings, training etc….Instructor role- ‘cognitive detective’Tries to figure out frames through using a ‘stance of curiosity’
Genuinely curious inquiry
Advocacy and Inquiry modelRudolph, J.W. et al., Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiol Clin 25 (2), 361-376 (2007).
“Phased-domain” debriefing
Team-orientedsimulatio
n
Team-orienteddebriefing
Domain-orienteddebriefing
Domain-orienteddebriefing
Domain-orienteddebriefing
Summary
MD
RN
SA
GROUP GROUP
A few final thoughts…
New role for debriefing?
To learn the skills to recognize ones own “limitations” (also described by some as
incompetence)
“To have such knowledge would already be to remedy a good portion of the offense” (Miller,
WI. 1993)
A possible future…
Debriefing and feedback become normative processes
encompassing all levels, domains and professional
identities of the healthcare system
A final note…Any simulation activity is a “snapshot-in-time”,It is reflective of the performance and behaviors which occurred during that specific time interval,It is not a positive or negative predictor of future
performance
SummarySimulation-based learning activities are supported by instruction (coaching) and facilitation (prompting and cueing)
Consider the types of feedback available, and employ those best suited to achieve the desired outcomes
Formulate a plan to provide structured debriefing following simulation activities
Debriefing should be learner-centric and conducted within a safe environment
Participants need and value the feedbackDebriefing points are derived through setting appropriate session/ course objectives
Questions and discussion
For additional information…Geoffrey T. Miller
Assistant Professor, School of Health Sciences
Director Simulation, Technology and Research
Sentara Center for Simulation and Immersive Learning
Eastern Virginia Medical School