The Art and Science of Debriefing: a Simulation Experience

Mary Cantrell, MA PULSE Center – Director Arkansas Children’s Hospital

Debriefing

The most important aspect of running any simulation Debriefing “Simulation is just a good excuse to do debriefing” Dan Ramer

Learning Model

Unconsciously – Incompetent Consciously - Incompetent Consciously – Competent Unconsciously - Competent

Your Best Teacher was…

• Smart • Wise • Caring • Concerned • Unspoken expert

How people practice

Internal Frames • EXAMPLES: • Thanksgiving is a day I eat all my favorite food.

• Dancing makes me look goofy • If I don’t leave work by 4:45 I will be stuck in traffic.

Learners Frames

• Feelings • Assumptions • Knowledge • Stuff I know is true • Stuff I learned in school

Frames shape actions

• Thanksgiving is a day I eat all my favorite food. – Eat all day – I can diet tomorrow.

• Dancing makes me look goofy – Don’t go near the party with a dance floor.

• If I don’t leave work by 4:45 I will be stuck in traffic. - Hurry all day to get it done because I don’t want to get home at 6pm.

Medical Frames & Actions

Residents don’t have any power… and I can’t tell my attending what to do.

When you do airway, you have to use an AMBO bag. I can’t find one and I think this patient is not going to make it. I just got out of school and everyone thinks I know what I am doing.

How do you define errors?

• Intentionally rational action • Seemed like a good idea at the time, given the circumstances.

• Lack of knowledge

Our Basic Assumption

Everyone participating in activities in the PULSE Center is intelligent, well trained, cares about doing their best and they want to improve.

Debriefers Job

• Help learner to surface their frames and analyze the impact on their actions.

• Be the UNSPOKEN EXPERT • Facilitate open/safe discussion

Debriefing leads to new frames Debriefing changes later actions Frames Actions Results

Judgmental Statements & Questions

• Can anyone tell us where John made his big mistake?

• Does someone have a clue as to what went wrong with this patient?

– Setting them straight – I’m right – You are wrong – I know --- you don’t (essential failure in thinking) – Truth------error (next time do it my way) – I know the answer- can you guess what I am thinking? – “pimping”

Non-Judgmental (???)

• I’m right – your wrong – but I don’t want to upset you. • “Feedback Sandwich” – Something soft (complement) – Something meaty (criticism) – Something soft (complement) Creates confusion Has hidden truths Consequences unclear

Debriefing with Good Judgment

• How did the learner make meaning of what happened • Instructor “From what I know this happened in the simulation and this is where I saw the problems” • Learner is also smart and well trained trying to do the best so… why did the learner take these actions? (they must have a good reason)

Errors are discussable

• Mistakes are made and recognized and then changes happen • Source of learning happens when you know what happened and how it can be different • Make mistakes discussable • Enhance patient safety • Let learners identify their own mistakes

Debriefing with Good Judgment

• Learner makes a mistakes • Debriefer is genuinely curious • Discuss what that looked like • Learners feel worthwhile and intelligent • Respectfully insert your expertise • Frame changes can happen!

Debriefing is Discussion (not lecture!)

• The Debriefer should talk less • Try only asking questions • Get the learners to talk to each other • Make it SAFE to discuss • Be a facilitator; not a lecturer • Closed ended questions – as appropriate • Open ended questions

Three Elements of Debriefing

Reactions – Feelings – Facts Understanding – Explore deeper meaning Summary – The take home message

Advocacy-Inquiry

• Advocacy – observation, statement, fact - neutral • Inquiry – question or curiosity* * GENUINE Curiosity (you want to understand)

Successful Debriefing

• Genuinely interested – You see yourself as the good teacher not the good healthcare worker • Pre-scenario briefing of expectations • Reinforcing good practice • Correct a limited number of errors • Avoid excessive correction (people only remember 1 or 2 things - what is the take home message?)

Successful, Con’t

• Stress key educational points • Use playback so the learners can see themselves • Talk less, facilitate more • Be respectful of any learner criticism • Use Advocacy – Inquiry • Plus /Delta

Plus/Delta

Encounter Detractors

• Lack of purpose, objectives • Excessive criticism, negative feedback • Humiliating a team member • Fixating on medical procedure

Encounter Detractors

• Underestimating the learner’s emotions/feelings • Lecturing • Hypercriticizing learner’s performance • Allowing discussion to focus on limitations of simulation

Debrief Roadblocks

• This would never happen • If this was a real case, I would have done things differently • No matter what you say, I don’t agree with you

Good Debriefing Questions

• How do you think that went?

• What did you do well?

• How would you do this differently next time?

• How do you rate your communication between team members?

Good Debriefing Questions

• What was not done?

• How did you feel?

• What do you think happened?

• Has this ever happened to you in the past, how did you react?

Good Debriefing Questions

• What did you see happening?

• Would you have done the same thing as _____?

• What information was being used?

• Did you need anything that was not there?

Thank you!

Mary Cantrell, MA University of Arkansas for Medical Sciences [email protected]

PULSE Center – ACH [email protected]