The Art and Science of Debriefing October 12, 2011

1. The Art and Science of DebriefingOctober 12, 2011 Betty Ishoy, MSN, RN-C

2. Make up of the Audience • Practice vs. Academia vs. _________ • Beginners vs. Intermediate vs. Super Users • Listened to a debriefing seminar before vs. read about debriefing vs. none • Main purpose in coming to this session today? My sim story What is debriefing? De-what?

3. Learning Objectives At the end of this session the participant will be able to: • Identify the goals of debriefing. • Discuss the elements of debriefing that improve outcomes. • Identify various approaches to debriefing. • Discuss the process of debriefing.

4. Is Debriefing Really Important? Learning outcomes are dependent on feedback and analysis at completion Key element to student learning (Cantrell, Meakim, and Cash, 2008) Crucial --Students strongly believed immediate debriefing enhanced learning—if wait it’s like “wait until Dad gets home” for discipline (what about waiting one hour?) Highly valued by students (Cantrell, 2008) In my experience, it is the MOST IMPORTANT part of the whole simulation experience.

5. BEME study recommendations for effective learning Study purpose: To review and evaluate the existing evidence, and to distill several important features and aspects of simulators that will lead to effective learning Provide feedback during the learning experience with the simulator. Learners should repetitively practice skills on the simulator. Integrate simulators into the overall curriculum. Learners should practice with increasing levels of difficulty (if available). Adapt the simulator to complement multiple learning strategies. Ensure the simulator provides for clinical variation (if available). Learning on the simulator should occur in a controlled environment. Provide individualized (in addition to team) learning on the simulator. Clearly define outcomes and benchmarks for the learners to achieve using the simulator. Ensure the simulator is a valid learning tool. BEME systematic review* Medical Teacher, Vol. 27, No. 1, 2005, pp. 10–28 S. B. Issenberg et al. http://informahealthcare.com.ezproxy.mcg.edu/doi/pdfplus/10.1080/01421590500046924

6. Tanner’s Clinical Judgment Model

7. Paucity of research regarding best practices of debriefing. We could spend the whole time reviewing debriefing literature. Education of faculty is a critical element.

8. Debriefers Thornton & Mueller-Hanson (2004) in their book, Developing Organizational Simulations: A Guide for Practitioners and Students, emphasize the importance of using ‘‘trained assessors to observe behavior, classify behavior into the dimensions being assessed, and make judgments about participants’ level of proficiencyon each dimension being assessed’’ (p. 5). Faculty training is imperative.

9. Role of Facilitator or the Debriefer The facilitator is not a neutral observer “The perceived skills of the debriefer has the highest correlation to the perceived overall quality of the simulation experience” (Wilhelm, 1991—military)

10. Role of Facilitator or Debriefer The facilitator: Sets the stage for an engaging learning environment Maintains an engaging context for learning Structures debriefing in an organized way Provokes interesting and engaging discussions and fosters reflective practice Identifies performance gaps Helps close performance gaps

11. Purpose of Debriefing • Ensures learning objectives are met • Helps students evaluate: ▫ their own performance ▫ the team’s performance (such as their communication) ▫ their understanding of the patient, the pt condition, and pt responses to the interventions • Helps students learn things they missed while engaged in their own role (Peters & Vissers, 2004)

12. Goals Of Debriefing Enhance critical thinking and problem solving Encourage collaboration and communication Comparing different perspectives increases understanding (Peters & Vissers, 2004) Reflect on emotions experienced (how do you students feel when the simulator deteriorates or dies? Ovarian cancer, end-of-life scenario) Safe place to discuss experience without time constraints and pressure Develop information seekers by having students utilize available resources (Don’t have to know all the answers, but what the good resources are) Correlate the simulated clinical experience (SCE) to real-world experiences, bridge the theory to practice gap Not just what went well and what went wrong

13. Positives and negatives of debriefing Components of a positive debriefing • Student-Lead • Affirming • Reflective • Informative • Verbal/written debriefing (addresses both types of learners) • Professional yet Relaxed Setting • Visualization of self (video) • Open-ended questions • Enlightenment • Learning • No Blame Environment “no mistakes just opportunities for learning” • Knowledge transference • Closing the theory to practice gap • Getting students to see self as nurse/expert clinician

14. Positives and negatives of debriefing Components of a negative debriefing Faculty-focused Lecture-like Off topic Haphazard Too quick (should be close to double the amount of time in scenario) Defensive student (video assists with this) Differences among debriefing faculty (need to develop consistency) Disingenuous feedback (less than authentic) Fractionation between curriculum, faculty, and simulation Accusatory or critical

15. How Is It Different From Post-conference? • All students have shared the same patient experience but from different viewpoints • Functioned as a team caring for patient – can they delegate and assign to each other? • Individual roles contributed to patient’s care • Video available • Logs from simulator’s computer available

16. Best Practices as identified by other nurse educators • Consistency among debriefers • Reflection/documentation and video debriefing. • Allow learner to lead discussion • Allow silence • Review and see therapeutic relationship, body language • Establish safe environment (confidentiality) • Debriefing double time of simulation • Prep before coming to simulation • Communication skills or positive role models for debriefers • Start with a positive • Debrief away from simulation • Empathy from faculty for those in student role • Live streaming • Collaborative effort for feedback • Student-led • Guided questions for observers or faculty • Immediate processing

17. Factors that inhibit debriefing as identified by other educators • Not enough faculty resources. • The facilitator (wants to teach everything) or a negative faculty member who talks down to student. • Vulnerability, not feeling comfortable enough to open up and share feelings. • Faculty/facilitator inconsistency. • Lack of preparation from the student. • Lack of evidence or “because I said so” or “let me teach you this, students” • Perceived hierarchy • Starting with negatives • Too many students • Not enough physical space • Not enough time to debrief • Participants leaving with a bad taste or negative experience • Lack of faculty buy-in or untrained faculty doing the debriefing Majority of negatives can be controlled by the faculty.

18. Situation(al) Awareness Shared mental model – all team members are “on the same page” 1. what has happened already 2. what is happening now** 3. what is expected to occur

19. “Frames” Each interaction is shaped by: Priorities (medical, nursing or personal) Knowledge and experience (or lack thereof!) Assumptions about how things will unfold These are factors that influence the “frame” of mind Teaching and effective communication are really processes of “reframing” - changing the frame of your colleague, your trainee, or yourself Rudolph, 2007

20. Let’s practice framing.AN ALTERNATE TITLE MAY BE: Getting the monsters out of your debriefing closet: Strategies for improvement

21. Monster’s Inc. Watch simulation Stop and talk about the monster Debrief the monster (Next slide) Then watch the movie debriefing Debrief the debriefing Debriefing positive: video-taped, immediate, possibly had good questions Not so positive: started with a negative, kept the student standing, questioned while student was standing, condescending tone of voice, right in the sim lab over the child/pt;

22. Monster’s Possible Frames He is stupid He is lazy He is distracted (personal - fight with wife) He is fixated on being very scary He is prioritizing his own escape route He doesn’t know what he’s supposed to do He thinks the open door adds an extra element of “scary” He might need backup from the monster world What else?

23. Best Practices from the Literature • Debrieifing should take place away from simulator, preferably another room; quiet (Johnson-Russell & Bailey, 2010) • Immediately after SCE completed • Professional learning environment (lab coats or uniforms) • Maintain confidentiality (HIPAA violation if disclosed) • Safe environment where the facilitator was present for SCE • Faculty promotes value of activity (Roger’s Diffusion of Innovation Theory—faculty buy-in) • Video allows learners to evaluate what actually happened—and not what they think happened (Fanning & Gaba, 2007) • Time of shared learning, rather than evaluation (Johnson-Russell & Bailey, 2010)

24. Best Practices from the Literature How long should debriefing last? IT ALL DEPENDS ▫ 2-4 times as long as scenario ▫ Longer for novice learners than experienced ▫ Longer for experienced learners as their scenarios are more complex ▫ Until the learning objectives are met (we do know the debriefing is the most valuable part, logical it should be as long or longer than the scenario; what if the group really gets it? What if the group totally doesn’t get it? It always takes longer for students to do stuff than you think) Don’t cut into debriefing. • UWG strategies (Reflection sheet and Checklist) to speed up debriefing • UWG sim schedule

25. Methods Of Debriefing Rudolph: 3 Step (Reactions, Understanding [A-I], Summary) Petranek: 4Es Events, emotions, empathy, explanations Plus/Delta (What went well? Better next time?) DASH method—Harvard (Debriefing Assessment for Simulation in Healthcare) Excellent behaviorally-based tool to assess the debriefer/debriefing. 7pt Likert scale with 6 key elements OPT Model of Clinical Reasoning (Outcome Present State-Test Model) (Kuiper, Heinrich, Matthias, Graham, Bell-Kotwall, 2008) Written--followed by or preceded by verbal debriefing Journaling Survey Monkey link w/in 24 hours

26. Effective Techniques Socratic, open-ended questions • “Why” them to death. • Talk to me about what prevented you from…. • Talk to me about what…. • “What were you thinking when ‘that’ happened?” • What interventions were necessary that were not performed? • Situational awareness questions and anticipatory questions Make relationship to real world problems—application, application, application. Encourage learners to look at their behavior ---Reflection: Reflection on action vs. Reflection in action even when distracted

27. Tanner’s Clinical Judgment Model

28. Effective Techniques Explore how group functioned as a team Address questions to group, not individual Be nonjudgmental; empathize ---put yourself in the student’s shoes, sometimes faculty take it personally Silence is not a problem! It’s thinking and processing time for the student Rephrase, reflect, reword, echo, repeat—I heard you say you were upset, can you explain that further, can you tell me more about that(Communication techniques) Student comments on teamwork, but not one-on-one peer eval (positive peer action can be effective)

29. Effective Techniques Advocacy-Inquiry Advocacy—provide the feedback to the learner by describing the mismatch between performance and the objectives or standard of care PAIRED WITH Inquiry—Genuine curiosity to understand the learner’s thought or “frame” that drove their actions or clinical decision making.

30. Examples Of Advocacy-Inquiry Dirty question: Why didn’t you call for help earlier? A-I: I noticed that you did not call for help until the pt coded and I was concerned that help earlier could have possibly prevented the code. What are your thoughts? No “guess what I am thinking” game. If we do not understand the thinking behind actions how can we change them? Practice A-I Why did you let the ptdesaturate? Why didn’t you give the NTG earlier? Why didn’t you call the physician earlier?

31. Recommendations Move away from plus/delta Recommend Common 4-step Formatfor Debriefing to Fulfill the Facilitator Role Introduction Personal Reactions Discussion of Events (Understanding) Summary

32. I. Introduction Communicate faculty expectations • Prepares learners to actively analyze and evaluate self and simulation activities • Honest communication How debriefing will proceed Describe faculty role • Facilitator vs evaluator or instructor Discuss confidentiality • What goes on in the sim lab stays in the simlab (HIPAA) Safe environment for expression of feelings and asking questions • Mistakes are part of the learning process, no punishment, not look bad in front of peers, criticism-free Consequences if the scenario is shared • other students robbed of the learning experience

33. II. Personal Reactions Recognize and release emotions built up during simulation (Fritzsche, Leonard, Boscia, & Anderson, 2004) Learners with opportunity to explore and deal with feelings experienced during simulation are better prepared to deal with them in real clinical situations (Henneman & Cunningham, 2005) • Let them express their personal reactions. Begin with open-ended questions • Reflective responses to student’s statements • Ensure that all have opportunity to respond (Sally, can you tell me something that Tim did well?)

34. III. Discussion of Events • Review objectives of SCE • During discussion, encourage participants to continually analyze the events in depth and their feelings, thoughts, and reactions to them ▫ Students learn and remember more when they participate actively and make their own analysis (Duvall & Wicklund, 1972) • Answer questions, clarify student thinking, emphasize teaching points (Fritzsche, Leonard, Boscia, & Anderson, 2004; Jeffries, 2005) • Guide students to the answers; use resources • Reflective Learning (Mort & Donahue, 2004) Self-assessment (Silent or spoken) Why you acted as they did, to correct it, to do differently? Individually, what do youneed to work on? • Encourage feedback from peers (Henneman & Cunningham, 2005) • Focus on performance, not performer

35. III. Discussion of Events • Ask Questions like: ▫ Tell me what happened? ▫ What did you do as a team or individually when that happened? ▫ What would you do differently next time, individually, as a team? ▫ What additional information, knowledge, skills, etc. do you think were needed in the situation? • Clarify Information ▫ Students may manipulate the data in such a way that they distort it and make it fit into their previous learning ▫ Through debriefing process, faculty can ensure that new learning is processed correctly (Chiodo & Flaim, 1993) ▫ Connect theory to practice

36. III. Discussion of Events • Question errors in judgment ▫ Complacency with abnormal VS ▫ Vigilance errors like failure to attend to changing status • Ask about communication with patient, family members, team members • Review charting • Review prioritization of care • Review published/standardized guidelines (Owen & Follows, 2006) • Acknowledge the unreality ▫ “No, the simulator is not a real person, but . . .” ▫ “You didn’t have a chart? Have you had a situation where you haven’t had everything you needed? What did you do in that case?” ▫ Will often try to blame the simulator if things go wrong • Link what has been learned in simulated setting to real world (Chiodo & Flaim, 1993; Fritzsche, Leonard, Boscia, & Anderson, 2004; Peter & Vissers, 2004) • How didactic and theory apply to patients with this condition

37. IV. Summary Goal is to assist students to look at overall experience: what they did, what they learned, what they want to work on Faculty can summarize or ask open-ended questions of the students to summarize: ▫ What did you learn that was new? ▫ What do you need to work on individually? As a group? Example: UWG blue sheet

38. IV. Summary End on a positive note (food works well) • “In summary, these are the things you identified as going well. . .” • “These are the things you told me you need to work on. . .” • “The take home points include. . .” • “I saw improvement in these areas. . .” Thank the students for participating in the SCE and debriefing Complete written work or evaluations

39. Debrief this performance • Goals are to provide safe, effective nursing care and keep the patient alive. http://www.youtube.com/watch?v=PQHPUkEViKk

40. Inhibiting the Debriefing • Instructor teaches content • Asks closed-ended questions • Answers questions before learner has chance to process • Judgmental and critical, belittling • Major focus is on errors

41. Other Considerations Simulated patient death or perceived death ▫ Debriefing is vital: support, reassurance, guidance knowledge (Allchin 2006; Walsh & guidance, Allchin, Hogan, 2003; Thiagarajan, 1992) Disruptive or dominant learners Critical of peers Disengaged learners

42. Faculty Debriefing of the Debriefing It’s important to improve our own performance. What worked, what didn’t? Any changes needed? What was learned about the students in general and about the curriculum? Review student evaluations Adjust as needed FACULTY SHOULD BE DEBRIEFED AT THE END OF THE SCENARIO OR SEMESTER. Review student evaluations of each scenario, sim program, faculty…survey monkey. Video tape debriefing to debrief the debriefer.

43. Learning Objectives At the end of this session the participant will be able to: • Identify the goals of debriefing. • Discuss the elements of debriefing that improve outcomes. • Identify various approaches to debriefing. • Discuss the process of debriefing.

44. Debriefing Today’s Session What did you learn today that was new? What do you need to work on individually? As a group? What best practice will you incorporate with your next debriefing? Thank you for coming and sharing bishoy@westga.edu

45. References Allchin, L. (2006). Caring for the dying: Nursing student perspectives. Journal of Hospice and Palliative Nursing, 8(2), 112-117. Chiodo, J. L., & Flaim, M. L. (1993). The link between computer simulations and social studies learning: Debriefing. Social Studies, 84(3), 119-121. Duvall, S., & Wicklund, R. A. (1972). A theory of objective self awareness. New York, NY: Academic Press. Fanning, R. M., & Gaba, D. M. ( 2007). The role Jeffries, P. R. (2005). A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96-103. Mort, T. C., & Donahue, S. P. (2004). Debriefing: The basics. In W. F. Dunn (Ed.), Simulators in critical care and beyond (pp. 76-83). Des Plaines, IL: Society of Critical Care Medicine. Owen, H., & Follows. V. (2006). Really good stuff: GREAT simulation debriefing. Medical Education, 40(5), 488-489. Peters V A M & Vissers G A N (2004) A of debriefing in simulation based learning. Simulation in Healthcare, 2(2), 115-125. Fritzsche, D. J., Leonard, N. H., Boscia, M. W., & Anderson, P. H. (2004). Simulation debriefing procedures. Developments in Business Simulation and Experiential Learning, 31, 337-338. Graling, P., & Rusynko, B. (2004). Kicking it up a notch- successful teaching techniques. AORN Journal, 80(3), 459-475. Henneman, E. A., & Cunningham, H. (2005). Using clinical simulation to teach patient safety in an acute/critical care nursing course. Nurse Educator, 30(4), 172-177. Hravnak, M., Tuite, P., & Baldisseri, M. (2005). Expanding acute care nurse practitioner and clinical nurse specialist education: Invasive procedure training and human simulation in critical care. AACN Clinical Issues, 16(1), 89-104. Peters, V. A. M., Vissers, G. A. N. 2004). simple classification model for debriefing simulation games. Simulation and Gaming, 35(1), 70-84. Rudolph, J., Simon, R., Rivard, P., Dufresne, R. & Raemer, D. (2006). There’s no such thing as “nonjudgmental” debriefing: A theory and method for debriefing with good judgment. Simulation in Healthcare, 1(1), 49-55. Rudolph, J., Simon, R., Rivard, P., Dufresne, R. & Raemer, D. (2007). Debriefing with good judgment: Combining rigourous feedback with genuine inquiry. Anesthesiology Clinics, 25, 361-376. Thiagarajan, S. (1992). Using games for debriefing. Simulation & Gaming, 23(2), 161-173. Walsh, S. M., & Hogan, N. S. (2003). Nursing students’ commitment of “Presence” with the dying patient and the family. Nursing Education Perspectives, 24(2), 86-90.