Simulation in Health Care: Debriefing in Healthcare Simulation Basic Skills

Simulation in Health Care: Debriefing in Healthcare Simulation Basic Skills

my name is Michelle Chu I'm an NC Z ologist and simulation director for the department of anesthesiology at the University of Ottawa I'm pleased to be talking to you today about some basic skills involved in debriefing after a simulation session first and foremost I have nothing to disclose the objectives of my talk today are for you to understand the principles underlying the debrief and to describe the various different phrases of debriefing so what is a debrief after completing a simulation scenario it's important for for you to spend time with the participants to talk about the events that occurred in the scenario in order to identify and address gaps in knowledge and performance fannie and Gabba define the debriefing as a facilitated or guided reflection in the cycle of experiential learning so why is debriefing so important well adult learners are our participants and as fanning puts it adults learn best when they are actively engaged in the process when they participate and play a role and experience not only the concrete events in the cognitive fashion but also the transactional events in an emotional faction when they actively experience something especially when it's paired with intense emotions this can result in long lasting learning this type of learning is best described as experiential learning reflection on the events experienced in the simulation scenario and the subsequent analysis is felt to be the cornerstone of the experiential learning process so why debrief at all well few participants actually repeat receive feedback in real life the simulation experience is very intense and their recall of the events and their decision-making is not automatic the challenge for you is to facilitate their recall and insight into what happened and why it happened some of the advantages to debriefing are that you can clarify learning points you can introduce key issues to the participants for further dialogue you can introduce insight into strategies and processes that lead to good results not just the results themselves and finally participants can begin to develop their own evaluative skills for future critical events so now we've gone over what the debrief is and why we debrief so here are the goals that you want to achieve in your debrief you want to enable your participants to become aware of their reactions during a crisis you want to help them develop tools for evaluating and analyzing their reactions and you want to affect a positive change in their behavior well that's all fine and dandy but now you may be asking yourself how the heck do I do this so what is the instructors role in the debrief so there are three phases of debriefing that you need to guide your participants through this is described as initially the reaction phase followed by the understanding phase and then the summary phase in the reactions phase what you really want to use this time for is just to clear the air and to guide the initial discussion questions like so how did you feel how that case went would be a good way of starting this phase remember that oftentimes if you walk with your participants to the debrief room you can also hear them talking amongst themselves about some of the issues that you might be wanting to address in your debrief so don't miss that walk through with your participants the understanding phase is the bulk of the of the debrief and you're going to use this time to try to understand what had happened and explore some deeper meaning of the events in this scenario so here you're going to use your time to try to discover what the learners frames are or what their mental models are of what occurred in the scenario and then finally the summary phase here you really want to take a few minutes to review what was covered in the debrief review what the participants learned and try to apply this to a larger context so you could say something like well let's identify a few take-home points that you'd like to take away from this case and apply to your future practice left to themselves most groups will have trouble moving beyond the reaction or the descriptive phase of the debrief especially the hot seat whose tends to be the most emotionally connected to the event so is Fanning and GABA put it there is a tension between making participants active and responsible for their own learning in the debrief versus you ensuring that they address important issues and they extract their maximum learning and so it's the debriefers job to acknowledge the emotions assist the group in defusing them and then guide the discussion towards concepts that can be more applicable in their practice so those are the principles how do you implement this well here are some suggestions for ensuring some effective debriefing divided into three components the debrief prep the pre briefed and the debrief itself which I've already have alluded to is broken down into your three phases of your reaction phase your understanding phase and your summary phase so the debrief prep occurs well before the participants arrive and before the simulation session begins here you want to deal with some of the logistics of the debrief for example the number of debriefers that you're going to be having in your session and their role just before starting just like in a resuscitation you want to ID the lead debriefer the second debriefer can be used as a backup person in case you're running into some trouble they can also be used to handle the video equipment if you're playing video this this preparation just prevents too many people from talking at the same time especially from a facilitator point of view you want to think about your seating arrangements think about where your audio-visual equipment is where's the screen if you're playing your video where is everyone sitting does everyone have a clear view of the of the video if you're videoing your debriefs make sure that the your camera is pointed out yourself and the participants so that you can take a look at your debrief after you want to think a little bit about how you sit in the debrief and your seating arrangements you want to if you know the people who are coming to your session put some of the more extroverted or talkative people scattered throughout the group and sort of the more introspective people scattered amongst so that you don't have a conversation that's heavy on one to the table and you also want to think about where the debriefers are going to sit you don't really want to have us versus them or a instructor on one side participants on the other sort of a seating arrangement you want to think a little bit about your role in the control room directing the actors and the Simtek or operator is going to be that person's role you want to make sure of course that the mannequins responses are accurate they're adequate and you are going to be the person who's going to be dealing with any emergencies that happen during the scenario on the fly so for example something simple like the the participant wants a drug that's not available you have to work with that or to something complex like your mannequin shuts down or freezes or stops working part way through the scenario how are you going to do that how can you direct your sim tech your Confederates to make that work and that's your role in the control room and finally of course you'll be observing your participants decision-making and there are crisis resource management skills so that you can speak about that in the debrief if you have audio-visual equipment in your system you might be recording on the AV equipment as well so you can make notes on your debrief as you are on the scenario as you discuss in the debrief so as you can see the the roles in the cut in the control room are very busy now the next section is the pre brief the pre brief is an essential component of the debrief this is a time that you have to establish a safe and engaging learning environment and the pre-brief usually occurs at the very beginning of your simulation session not after a scenario and before the debrief so as your participants come into your session you will have everyone sit down and have the pre briefed and then launch into your teaching curriculum so during this time you want to be using this time to clarify some course objectives you want to explain a little bit of the environment especially if a participant hasn't arrived there before explain a little bit about the simulator that you'll be using the environment the equipment that you'll be using explained if there's going to be certain crash cards or defibrillators orient them to where everything is explained to them about the role of a Confederate if you have one they're there to assist in this scenario that they may have a mic or a headpiece and that's just to allow for communication but they're there to help you as best that they can so you really want to make explain as much as you possibly can to make it a less threatening environment you also want to ensure that confidentiality is emphasized both ways not only that people are not going to go out and talk about the scenarios and the debriefings that just occurred but also that that you're not going to be talking about their performance if this is a formative session again that makes it very reassuring for people who are sort of coming and putting themselves out there in the scenario itself we spoke a little bit about the environment making sure it's a comfortable environment if you have refreshments available you can leave them there in the table and have them know that that's available to them you want to make sure that the that there is some privacy to the area not everyone has the luxury of going to a separate debrief room where a door can be closed for debriefing certainly if you have that luxury I encourage you to make sure that the door is closed that the hallway traffic doesn't distract from the debrief if you are in the simulation room or in the control room just to make sure that other extraneous people are not in the room there with you or coming in and out as you're trying to debrief because that can be very distracting and make people feel a little bit vulnerable obviously introductions are very important just to make sure everyone around the table knows everyone else and that they know who you are and what your role is again with expectations and roles you want to explain that the their participants role in coming to the simulation center for this session is to engage in a debriefing in a polite and respectful and self reflective way to explain that after this scenario there will be some time spent discussing what had happened and that it's important to make sure that everyone is very respectful in that time and it's also important for you to explain your role that your role is to facilitate and not to didactically teach so that your role is to facilitate discussion about the events that occurred and another important aspect of the pre-brief is to establish action contract so again establishing trust and credibility is really important for people to be able to reflect and learn and a fiction contract has been described as sort of a joint contract that the instructor and the participants create together so the instructor acknowledges that the simulation is none not exactly like real life but we try in every way to make it as realistic as possible we if there are any artifacts or problems with the simulator that you've noticed that day now is the time to disclose that to your participants so that they don't feel like they're being tricked in this scenario and you also want to ask the participants to try their best to act as if things are real to suspend disbelief in other words the acknowledge the fact that they may put you know act differently in the simulator than they do in real life and that's that's a known aspect of teaching in the simulation center you want to take the time to attend to some logistical details make sure that not only is the debriefing room clean ready enough chairs for everyone make sure that they know if there's food or drink available but also let people know where the washrooms are when would be a good time to go to the washrooms and sort of set up some guidelines that way and you essentially want to use this time to convey a commitment to them that they're going to be respecting their learning and respecting and understanding their perspective the participants often worry that simulations are really designed to expose their weaknesses or to make them feel humiliated or bad for themselves you want to acknowledge that the simulation experience can be stressful but that this is normal and that to tell them that as instructors you're always holding the basic assumption that the participants are intelligent they're competent and they're here to try their best you really want to focus on simulation as an opportunity not an experience to be survived and that mistakes are really sort of puzzles to be to be solved rather than been true mistakes to feel to feel bad about it's okay to make mistakes and this is okay because you're here to to learn about improving practice so as you can see this is a really large component and I'd encourage you to make sure that you schedule enough time in your simulation session to be able to cover all these concepts and to be able to answer questions that participants might have about their session before it happens okay so now on to the debriefing itself let's assume that you've finished your scenario before you enter the debriefing room if you have a co debriefer huddle with them and I use the word huddle because it's kind of like a just a few seconds or minutes where you can talk a little bit about what you both saw in the scenario maybe some issues that you maybe both want to bring up and just to confirm that you're both on the same page about the debrief before you enter the debriefing room you also might want to use this time to ask your co debriefer to cue up a video to a certain point so they can work on that while you're initiating the initial discussion with your participants when you get in the debrief room start up with some general questions how did it go what did it feel like it allows the participants to diffuse brings down their emotional state and it can give you good hints into what their insights are onto how the scenario went and maybe some insight into some of the issues that they might want to discuss that you actually hadn't identified and what this also does is it gives a very clear message to the group that their input is very clearly valued and it's not just your agenda that you're going to go on this debrief with you want to take this time as well just to make sure that everyone is fully briefed so that everyone has the same mental model about what was happening in the scenario so I usually tell people just to you know if you could just take three or four sentences one or two minutes to just make sure everyone is everyone knows what had happened at the beginning of the deep' at the beginning of the scenario so for example Bob you are in first what had happened there before you called for help and this is often the best time to establish credibility and Trust with your group so again that was the reaction phase a few minutes there and soon afterwards you'll enter into the understanding phase so you want to ask the group to identify any important issues that they they may perceive you want to begin with some of the relevant medical or technical issues if they just didn't know how many joules they were supposed to use when they defibrillated or the dose of epinephrine to use now is the time to deal with those sorts of issues because if you try to delve into some of the more complex issues in the back of their mind they'll still be thinking about what dose they should have used and they really probably won't be focused completely on what you're saying you want to ensure that everyone is included in the discussion you'll naturally have people that are more talkative maybe a little bit nervous and very sort of forthcoming you also probably have those that react to simulation in a very introspective way so you'll want to sort of get a sense of the mood of the room and try to facilitate input from everyone in the room some of the ways that you can move through the understanding phase is to prioritize key strategies and correctable behaviors there may be so much that you want to talk about but you really only have a limited time so focus on some really important points that you want to to make sure that they leave with you want to make sure that you address their behavior and not their personality the feedback on personality is often quite judgmental it's perceived as very subjective whereas feedback on observable behaviors is much more palatable so instead of saying something like you're really slow there you might say something like you know it took you a minute to respond do you remember what you were thinking or instead of saying that was you were really you couldn't make up your mind you're very indecisive you could say something like well you didn't respond to the nurses question why was that you want to address specifics rather than generalities so instead of saying something like I think your communication was poor you can say something like communication can be improved by directing comments at a specific person take away your own subjectivity as a debriefer as an instructor you'll come out with your own sort of impressions on how things are but rather than making statements about that be very specific and generalize them to the facts that you see read and directing it directly at a participant so again instead of saying well you didn't communicate that point very well you could say directing communication and avoid repeating orders to people another way to move through the understanding phase is to involve the group so it fosters a very open atmosphere you can provide a balanced perspective and it gives you credibility because it's not just you talking it's it's their peers you can encourage inquiry into the motivation behind their actions and reinforce some of those crisis resource management principles and then also other people can answer some of the questions that you are proposing and that takes a little bit of the pressure away from the hot seat or the the person who is the lead person in that scenario the support staff or the second instructor can also be speaking and that removes the sort of the judgmental type of perception but just be careful that you're not always tag-teaming because then it makes it feel like it's you're kind of piling on the the judgment you can also use the group to move your discussion along in a different Avenue and change the focus of the discussion this way really consider using the video a lot of people when they start out find it very difficult to manage the group and manage the video and showing video at the same time but it's a very very effective way of allowing the participants to see what it actually happened because they may their recall of what happened may be completely different from actually what what actually happened so try to use the video as much as possible because it makes it very objective the important thing about using the video is to make sure that you clearly orient the participants to what is going on so that not everyone is thinking about different things when they watch it so you want to introduce a video clip by saying for example okay well we are having a discussion a little bit about the handover and there seems to be some confusion so why don't we watch the handover here again and everyone just focus on what was said and what was received so by directing your your comments in that very specific way people are going to be focusing on those specific conversations or comments rather than looking at themselves on the videotape and wondering oh why am i standing over there doesn't my hair look funny or something like that so it helps you guide your discussion in a time efficient way and finally flexible there's a lot of structure here that you can start with you may find that your participants have other things that they want to talk about and and those things are maybe just as important so be ready to have a few things on your agenda that you want to talk about but make sure that you make time for a few of their things that they want to talk about too because again perhaps what you had imagined was the the learning from this scenario may actually be very different for different groups as they come through so finally it's important to realize that all things may come to an end you're probably wishing that the bad ones end quickly but the good ones need to end too so in the summary phase you can ask for some final questions and comments and you can use some of these review questions to reinforce your learning points for example what did you do well and why this is very difficult for participants to come up with they automatically focus on things they wish they did differently or things I felt they did bad on but I think it's important for them to lead realizing that they do have skills that are excellent that they practice those skills and it's good to reinforce those as well what did you find difficult and why I don't like to use the word wrong because again it's very judgmental but they people do find some things were more difficult and I think that's a reasonable question to ask and how they would improve on that anything that you would do differently next time and why and then finally what did you learn and oftentimes people have a very very intense experience and there's a lot of things that they they learned but you might want to make it even more focus by saying what was one thing that you learned from this scenario and debrief that you take away to apply to clinical practice and it really helps them focus on that and might help them reflect on that later on so you want to also finish the debrief by summarizing some of the main points this ensures a positive feedback of some of the principles that you wanted to teach in your in your simulation session and it just allows for a natural conclusion to this scenario or to the debrief and try to end on a positive note so some parting words as you embark on your debriefing career the debriefing skills that you develop they're very generic they can be practiced daily you're trainees and your colleagues your spouse is at home the debriefing is the hardest part of running a simulation course but your skills will develop with practice and time and they will grow and above all else have fun thanks for listening you

One comment

  1. Nice video. You may also want to checkout the review of Basic skills on my blog at bradleyreviews. com/basic-skills-review/ Thanks. Bernardo.

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