Introduction

The learning that takes place in medical simulation settings is largely experiential in nature. Participants experience a novel situation in a simulated scenario, and subsequently reflect on it, deepening their understanding of the relevant aspects of healthcare and (it is to be hoped) modifying their future behavior in the real world . One important factor which affects this post-experience reflection is the quality of the associated debriefing and analysis. Debriefing is the act of reviewing critical actions that unfolded during the course of a simulation scenario.[1] The process of debriefing and its timing can take on many forms and techniques; regardless, the process should be learner-focused. The process of debriefing and the process of feedback are sometimes used interchangeably; however, they are distinguishable one from another.  Debriefing is conversational, bidirectional, interactive, and reflective, while the process of feedback is unidirectional and informational, providing a learner with key information about aspects of performance.[2]

Function

There are multiple forms of debriefing when it comes to content.  Promoting Excellence and Reflective Learning in Simulation (PEARLS); Team-Guided team self-correction, Advocacy-Inquiry, and Systemic-constructivist (TeamGAINS); Defusing, discovering, and deepening (3D); Gather, Analyze, and Summarize (GAS) are just some of the forms that debriefing can take and are described elsewhere.

Regardless of the content, debriefing is rooted in providing learners with a psychologically safe environment.  Learners and faculty should have a shared mental model with and an underlying assumption that everyone wants to learn and improve upon their current foundation of knowledge.

Issues of Concern

Debriefers should be trained to recognize and intervene in difficult situations so that the benefits of simulation are not compromised. Common issues that surface include quiet learners, disengagement, conversation domination with or without proper knowledge and insight, and emotional reactions.[3] Debriefers should also be aware of cultural differences that may play into how learners react and interact in the reflection period after simulation.[4]

Clinical Significance

Why should you debrief?

The process of debriefing is one of the most important aspects of simulation design. This component allows learners to reflect on tasks that they performed well, tasks that need improvement, and the opportunity to clarify knowledge gaps.  The process of debriefing facilitates adult learning, enhancing self-efficacy, and responsibility in the learning process.  In doing so, learners can add to their working body of knowledge, promoting the transfer of learning, and faculty and learners can share a similar mental model of benchmarks.[5][6] Research has shown that learner-centered activities contribute to more prepared graduates than those who participate in instructor-centered courses.[7] 

Rapid cycle deliberate practice

Stop-and-go debriefing has been utilized in simulation scenarios focused on mastery learning. This process has been gaining momentum as the theory behind its use contributes to more opportunity to hone skills, especially for high stakes clinical scenarios, such as resuscitation. This process is also known as rapid cycle deliberate practice (RCDP).[8]  During RCDP, learners have the opportunity to practice one skillset until achieving mastery, and then in a step ladder approach, more complex action items are added. After each phase, small debriefings take place with feedback and discussion taking place.  During a traditional reflective debriefing, learners and faculty debrief at the conclusion of the scenario and may not have the opportunity to practice the scenario immediately.

Debriefing on demand

Debriefing on demand can help in scenarios that have the potential to generate stress and anxiety. One study examined the benefits of this model with novice postgraduate residents. Guided facilitation through complex problems could occur when a learner identified a point in time during the scenario when he/she became overwhelmed or perplexed. The scenario can pause in place and resume during a quick period of reflection. Learners identified that this process allows for clarification, decrease in stress, and thus contributes to knowledge retention and transfer of skills more effectively.[9]

Video-assisted debriefing

The theory of video-assisted debriefing (VAD) allows learners to review the actual performance of the scenario as opposed to recalling and relying on other individuals to correctly relay information. Conversely, learners often exhibit reluctance to have themselves video recorded, becoming self-conscious.[5] This process has also been utilized for task training skills, such as suturing and laparoscopic techniques. This particular method is useful for remote mentoring.[5]  VAD is also a helpful tool when multiple individuals are actively participating in the simulation and when a variety of critical action items require monitoring. It also can be used to help learners gain insight into less objective behaviors such as body language.

Instructor vs. peer-led debriefing

Properly trained faculty requires a significant investment and time. Programs that have a large volume of students have been leaning towards the use of peer-led debriefing. While some studies point to virtually no or minimal differences in knowledge and self-confidence, the quality of debriefing does differ with learners noting that instructors provide more feedback and solutions.[10] An added benefit of peer-led debriefing is the facilitation of collegial skills, mutual respect, and bonding between learners.[10]

Written tools for the debriefer

The art of debriefing requires training and expertise.  Written tools have been designed to facilitate debriefing to ensure that the process maintains a learner-centered focus and remains nonjudgmental. These tools can be particularly beneficial to novice debriefers.  Debriefing sessions performed by faculty that lack adequate training can disrupt the tenets of simulation, threatening knowledge retention, and creating an unsafe environment.[3]

Written debriefing for the learner

There has been some investigation into the potential to incorporate written debriefs in the post-simulation period.  The theory is that written debriefs can lend themselves to higher insight into the individual learning process.[3]  Learners received the option to participate in an oral debrief versus journaling. In this small cohort, learners derived more benefit from the oral debriefing process and cited that written debriefs were often a hassle.

Co-debriefing

The process of co-debriefing can be challenging; both individuals need to have a shared understanding of the process, along with mutual respect.[11] A recent publication highlighted some of the challenges that can occur with co-debriefing and how to prevent issues from occurring. For example, co-debriefers should position themselves across from each other so that nonverbal cues can help coordinate the conversation, along with the segue into subsequent topics. Co-debriefers should also remain cognizant of how their contribution may lead to an interruption of a stream of thought by the other individual.[12]

Pearls and Other Issues

Debriefing is a critical component of simulation exercises. Without debriefing, incorrect mental models are often reinforced rather than corrected.

A preconceived debriefing plan is essential to ensure the addressing of critical actions.

Effective debriefing requires training and practice.

Enhancing Healthcare Team Outcomes

Debriefing in interprofessional groups allows learners the opportunity to discover how teams can function together, communicate more effectively, and better understand each other’s roles.[13] The role of the debriefer becomes crucial when dealing with interprofessional teams as multiple aspects need to be addressed due to the variable scope of practice amongst the participants and how interdependence can affect team members.[11][14] The debriefing should also focus on how to remediate an individual’s performance versus team performance.[14]