Geoffrey T. Miller Assistant Professor, School of Health Sciences

1. The Art and Science of Debriefing Debriefing, 听取汇报,comentários, maoni,フィードバック,terugkoppeling, ردود الفعل,প্রতিক্রিয়া,Rückkopplung,thông tin phảnhồi, обратная связь, Debriefing, 听取汇报,comentários, maoni,フィードバック,terugkoppeling, ردود عل, প্রতিক্রিয়া, Rückkopplung, thông tin phảnhồi, обратная связь, Debriefing, 听取汇报,comentários, maoni,フィードバック,terugkoppeling, ردود الفعل, প্রতিক্রিয়া, Rückkopplung, thông tin phảnhồi, обратная связь, Debriefing, 听取汇报,comentários, maoni,フィードバック,terugkoppeling, ردود الفعل, প্রতিক্রিয়া, Rückkopplung, thông tin phảnhồi, обратная связь, Debriefing, 听取汇报,comentários, maoni,フィードバック,terugkoppeling, ردود الفعل, প্রতিক্রিয়া, Rückkopplung, thông tin phảnhồi, обратная связь, Debriefing, 听取汇报,comentários, maoni,フィードバック,terugkoppeling,ردوعل, প্রতিক্রিয়া, Rückkopplung, thông tin phảnhồi, обратная связь, Debriefing, 听取汇报,comentários, maoni, 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

2. 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

3. 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.

4. Human processing in action… ARE YOU HAPPY? DO YOU WANT TO BE HAPPY? NO CHANGE SOMETHING YES KEEP DOING WHATEVER YOU’RE DOING NO YES

5. Human processing Natural order of human processing Reflect on it Experience an event Discuss it with others Learn & modify behaviors based on the experience

6. Why feedback/debriefing matters… • B • C • D A A A = Education A B = Things you know C= Things you know you don’t know D = Things you don’t know, you don’t know

7. Feedback…Debriefing… isn’t it all just the same thing?

8. 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 learning • Appears to slow the decay of acquired skills • Allows for self-assessment IssenbergSB,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.

9. 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

10. 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.

11. Factors influencing debriefing • Objective of the experiential exercise • Complexity of the scenario • Experience level of participants • Experience level of participants with simulation environment • Time available for the session • The role of the simulation in the overall curriculum • Individual personalities and relationships, if any, between the participants

12. Debriefing myths… and realities

13. Debriefing myths… “There is a highly defined process or method for conducting learner debriefing”

14. 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.

15. Debriefing myths… “The most effective facilitation is achieved when the learners or participants do all of the talking… not the instructor”

16. 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.

17. Debriefing myths… “Debriefings should always be conducted in a separate space or environment”

18. Debriefing myths… “Debriefings should always be held after the simulation ”

19. 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)”

20. Debriefing considerations

21. 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)

22. Identifying & closing the gaps Observable performance Performance perception Performed well Feels good Performed well Feels bad Performed poor Feels poor Performed poor Feels good GAP Knowledge Skill Behavioral

23. Simulation-debriefing relationship Activated Excited Alert Elated Happy Stressed Upset Nervous Tense Simulation Debriefing Pleasant Unpleasant Relaxed Serene Content Calm Bored Sad Fatigued Depressed Inactivated

24. Coaching, prompting & cueing • Coaching • Directing, instructing and training a person or group of people, with the aim to achieve some goal or develop specific skills • Prompting • To move to action • Cueing • Giving verbal or non-verbal triggers/clues for an action to be carried out at a specific time Instruction Facilitation

25. Debriefing ‘Dose’ “Debriefing Amount / Time will decrease with higher learner expertise, It will not reach zero” Debriefing Amount/Time Learner Expertise Novice Expert

26. Lots of debriefing modes • Private 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

27. Feedback, debriefing & deliberate practice Sim Sim Sim Change Change Change Ericsson’s Model of Deliberate Practice: “Practice does not make perfect… practice makes permanent” Prep Prep Debrief Prep Debrief Debrief 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.

28. Important debriefing points/skills • Be genuine and student centric • Ask 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 feedback • Use probing inquiry to gain deeper understanding

29. Perspective on use of video Use if necessary; typically to observe specific events or processes Have 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

30. Debriefing Models

31. Structured &supported debriefing (SSD) 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. • 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 considerations • Simple, can be learned rapidly, scalable, validated by practice

32. GAS Model Goal: Listen to participants to understand what they think & how they feel 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?” G GATHER 25%

33. GAS Model Goal: Facilitate reflection on & analysis of actions 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…” A ANALYZE 50%

34. GAS Model Goal: Facilitate identification & review of lessons learned 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…” S SUMMARIZE 25%

35. 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

36. Debriefing With ‘Good Judgment’ Trainee ‘Frames’ Approach Frames to Actions to Results • A frame is the internal trainee environment • Perceptions, 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 model Rudolph, J.W. et al., Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiol Clin 25 (2), 361-376 (2007).

37. “Phased-domain” debriefing Team- oriented simulation Domain- oriented debriefing MD Team- oriented debriefing GROUP Summary GROUP Domain- oriented debriefing RN Domain- oriented debriefing SA

38. A few final thoughts…

39. 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)

40. A possible future… Debriefing and feedback become normative processes encompassing all levels, domains and professional identities of the healthcare system

41. 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

42. Summary • Simulation-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 feedback • Debriefing points are derived through setting appropriate session/ course objectives

43. Questions and discussion

44. 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 Millergt@evms.edu