The term teledebriefing describes a process in which learners who are participating in a simulation scenario undergo debriefing with a facilitator located at an off-site location. The concept of educating or training learners at an off-site location is a relatively new niche in the field of medical simulation, called telesimulation. Specifically, telesimulation is a process by which telecommunication and simulation resources are utilized to provide education, training, and/or assessment to learners at an off-site location. Although literature exists describing the use of simulation and telecommunication resources for medical education, there had not been a unifying definition for the term telesimulation until recently. In 2016, a new comprehensive and unifying definition was introduced to the simulation community at the International Meeting on Simulation in Healthcare that encompasses all the areas utilizing telecommunication and simulation resources for education & training had been used in the past while allowing for future growth in all learning domains.
Telesimulation has seen rapid growth in the last several years and has been implemented in many areas, including (but not limited to) pediatric resuscitation, surgery, anesthesia, nursing, and emergency medicine. The benefits of using telesimulation in medical education are many and include the ability to education and train learners at an off-site location; the ability to assess learners at an off-site location eliminates distance and time barriers to content delivery, allows for inter-institutional networking/collaboration, and can provide significant cost savings to individuals, programs, and institutions.
In a simulation, debriefing is often considered to be the most crucial component and is the time when a majority of the learning occurs. Using cameras, microphones, and basic videoconferencing software, telesimulation allows learners to connect to instructors at an off-site location. Teledebriefing involves a faculty member in a remote location, who through using videoconferencing technology, provides feedback while watching the simulation in real-time. Teledebreifing in telesimulation allows the conferring of the benefits of simulation beyond the walls of simulation centers.
Research has shown that simulation is a superior educational modality compared to passive methods such as didactic lectures for critical care conditions. As such, simulation is becoming increasingly incorporated into medical education. However, in many areas of the world, there is a paucity or absence of simulation resources, limiting the benefits of simulation in resource-poor/restricted areas. Furthermore, at teaching institutions with simulation facilities, the number of qualified instructors that can facilitate post-simulation debriefing may be inadequate, limiting the benefits of simulation. An emerging solution to this problem is telesimulation.
By utilizing telesimulation with teledebriefing, facilities which are lacking faculty resources may gain access to simulation education by the use of basic equipment and a simple Internet connection.
Implementing telesimulation into educational curriculum requires (at a minimum) resources that include (but are not limited to):
- Simulation equipment (ranging from simple procedural task trainers to high-fidelity mannequins)
- Telecommunication equipment that allows the capture and transmission of audio/visual data (can vary from a simple smartphone to full simulation audio/video software programs)
- Internet connection
- Software that has teleconferencing capabilities
In resource-poor/restricted areas, this concept is beneficial since it eliminates the time and distance barriers to the delivery of educational content.
The body of literature supporting the effectiveness of telesimulation is growing. Among these is a prospective, randomized crossover study that examined the effectiveness of telesimulation versus standard simulation in teaching medical students the management of critically ill patients. The study demonstrated no significant difference in evaluation scores (which assessed the learner's comprehension of the educational material delivered) between the two groups of medical students, nor in the favorability of teaching modality (telesimulation vs. standard simulation). The authors concluded that telesimulation could provide educational benefit to learners at off-site locations.
Issues of Concern
Tips for Implementing Teledebriefing
Teledebriefing can be accomplished cost-effectively and straightforwardly using basic equipment and an Internet connection. To capture audio and visual information, telesimulation studies have demonstrated efficacy utilizing equipment such as webcams, smartphones, tablets, and microphones and headsets. An innovative study investigated telesimulation in teaching mass casualty triage utilizing wearable technology to deliver emergency medical services (EMS) course on mass casualty incident (MCI) training to healthcare providers overseas. In this feasibility study, the authors demonstrated the successful implementation of an intercontinental MCI triage course using telesimulation and wearable/mobile technology.
Telesimulation allows learners to benefit from the simulation in large part by overcoming time, distance, and limited human resource barriers. Teledebriefing is one process in telesimulation that allows learners to benefit and gain knowledge and skills from subject matter experts/educators that are not on-site. Teledebriefing also allows subject matter experts the ability to share their expertise and provide value to the community without having to travel extended distances or take the additional time to be physically present at the site of instruction; this can be particularly beneficial for those educators who travel nationally and internationally to provide educational content to learners.
Teledebriefing is a process in which learners participating in a simulation scenario undergo debriefing with a facilitator located at an off-site location. There is a myriad of specific debriefing techniques that utilizable with teledebriefing. For example, the Plus/Delta technique of debriefing focuses on learner self-assessment. The debriefer will ask open-ended questions such as "What went well?" (plus) and "What could be changed?" (delta), to identify issues that may have occurred during the case to improve future performance. This technique may also be useful in the debriefing of systems-focused simulations (e.g., in-situ code blue team simulation).
Rapid Cycle Deliberate Practice (RCDP) is a technique of debriefing that has demonstrated effectiveness in simulation scenarios designed to teach procedures such as airway management, technical skills, and adherence to resuscitation guidelines. It differs from traditional post-scenario debriefing by moving the debriefing to occur within the scenario itself. In RCDP, the scenario gets paused if participants perform an action incorrectly, and they receive immediate feedback and correction by a facilitator. The case then "rewinds," and the participants are allowed to practice the action again, this time doing it the "right way." Upon the mastering of a skill, the scenarios progress in difficulty, built on previously mastered skills.
Advocacy inquiry is a technique where the facilitator first advocates his/her observation of an action or behavior and then inquires about the participant's frame of mind relative to the action. An example of an advocacy-inquiry exchange could be an instructor saying, "I noticed you had two unsuccessful intubation attempts while the patient was actively seizing (facilitator advocates his/her observation). I was worried about the potential of you getting bitten by the patient during your attempt to open the mouth (shares his/her point of view). I was curious as to what was your thought process as you worked to increase the patient's oxygen saturation during the seizure (facilitator inquires about the underlying mental frames that lead to the action)?"
The GAS (Gather Analyze Summarize) conversation structure is yet another debriefing method that is also commonly used in medical simulation. In this 3-phase debriefing method, the facilitator encourages the participants to provide a recapitulation of the simulation events (gather), stimulates learner-centered reflection and analysis to evaluate mental models (analyze), and ensures that the learning objectives have received adequate coverage and reviews lessons learned (summarize). Regardless of the specific type of debriefing method, teledebriefing expands learning opportunities for participants who would otherwise not have the educational experience owing to time, distance, and subject matter expert resource challenges.
Debriefing is arguably the most critical part of the simulation session that pertains explicitly to knowledge consolidation. There is now a small but growing body of evidence addressing this aspect of telesimulation. A study that examined the efficacy and feasibility of teledebriefing as an alternative to in-person debriefing found that teledebriefing was rated slightly lower than in-person debriefing, but was still found to be consistently effective. The authors of this study came to the conclusion that since the overall rating of teledebriefing was very high (receiving a score of "consistently effective/very good" on the Debriefing Assessment for Simulation in Healthcare Student Version (DASH-SV)), it may be a practical alternative to debriefing if faculty or staff is unavailable to provide traditional in-person debriefing for simulation-based medical training.
The authors also report the possible reasons why teledebriefing was rated lower than traditional debriefing. These included the loss of non-verbal cues (in part due to the debriefer only being viewable from the shoulders up on the video screen), the inability to demonstrate maneuvers or procedures physically, and the inability of teledebriefing faculty to visualize or hear subtle forms of communication between participants during their observation of the simulation session. In addition to the limitations mentioned above, technological and time-zone discrepancies can also provide challenges to implementation. However, despite these limitations, teledebriefing offers a practical and viable option to educate learners who otherwise would not have access to on-site subject matter experts with experience in debriefing.
Enhancing Healthcare Team Outcomes
Simulation encompasses any processes or technology that recreate a contextual background that allows learners to make decisions, experience success and mistakes, receive feedback, and gain confidence in an environment that is void of patient risk. This approach may be particularly useful for low-frequency but high-acuity scenarios. The Institute of Medicine, the Educational Technology Section of an Academic Emergency Medicine Consensus Conference, and the public have advocated for increased simulation-based training to reduce error. The Association of American Medical Colleges adopts the position that simulation is arguably the most prominent innovation in medical education over the past 15 years. Simulation in medical education and training has the potential to revolutionize healthcare education, healthcare delivery, quality improvement initiatives, and address patient safety issues if appropriately utilized and integrated into the educational and organization improvement process.