Introduction

Teledebriefing describes a process in which learners participating in a simulation scenario undergo debriefing with a facilitator at an off-site location.[1] 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, or assessment to learners off-site.[2] Although literature describes the use of simulation and telecommunication resources for medical education, there has not been a unified definition of telesimulation until recently. In 2016, the International Meeting on Simulation in Healthcare introduced a new comprehensive and unifying definition to the simulation community. It encompasses all the areas utilizing telecommunication and simulation resources for education & training that had been used in the past while allowing for future growth in all learning domains.[2][3][4][5] 

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.[2][3] The benefits of using telesimulation in medical education are many and include the ability to educate 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 interinstitutional networking and collaboration, and can provide significant cost savings to individuals, programs, and institutions.[2][6] 

In a simulation, debriefing is often considered the most crucial component and is when most of the learning occurs.[1][7] Using cameras, microphones, and basic videoconferencing software, telesimulation allows learners to connect to instructors off-site.[2][3] Teledebriefing involves a faculty member in a remote location who, through using videoconferencing technology, provides feedback while watching the simulation in real time.[1] Teledebreifing in telesimulation allows the conferring of the benefits of simulation beyond the walls of simulation centers.

Function

Research has shown that simulation is a superior educational modality to passive methods such as didactic lectures for critical care conditions.[8] As such, simulation is becoming increasingly incorporated into medical education.[1] However, there is a paucity or absence of simulation resources in many areas of the world, limiting the benefits of simulation in resource-poor or restricted areas.[4] Furthermore, at teaching institutions with simulation facilities, the number of qualified instructors that can facilitate postsimulation debriefing may be inadequate, limiting the benefits of simulation.[1] An emerging solution to this problem is telesimulation.

Utilizing telesimulation with teledebriefing, facilities lacking faculty resources may gain access to simulation education using 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 or visual data
  • Can vary from a simple smartphone to full simulation audio or video software programs
• Internet connection
• Software that has teleconferencing capabilities [2]

This concept benefits resource-poor or restricted areas by eliminating the time and distance barriers to delivering educational content.[2] 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 benefits to learners at off-site locations.[9]

Issues of Concern

Tips for Implementing Teledebriefing

Required Equipment

Teledebriefing can be accomplished cost-effectively and straightforwardly using basic equipment and an Internet connection.[2] Telesimulation studies have demonstrated efficacy in utilizing webcams, smartphones, tablets, microphones, and headsets to capture audio and visual information.[1][4][7] An innovative study investigated telesimulation in teaching mass casualty triage utilizing wearable technology to deliver emergency medical services (EMS) courses on mass casualty incident (MCI) training to healthcare providers overseas.[4] In this feasibility study, the authors demonstrated the successful implementation of an intercontinental MCI triage course using telesimulation and wearable or 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 who 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.

Debriefing Techniques

Teledebriefing is a process in which learners participating in a simulation scenario undergo debriefing with a facilitator at an off-site location. There is a myriad of specific debriefing techniques that are utilizable with telebriefing. For example, the Plus/Delta debriefing technique focuses on learner self-assessment. The debriefer asks 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 debriefing systems-focused simulations (eg, in-situ code blue team simulation).[10][11] 

Rapid Cycle Deliberate Practice (RCDP) is a technique of debriefing that has demonstrated effectiveness in simulation scenarios and is designed to teach procedures such as airway management, technical skills, and adherence to resuscitation guidelines. It differs from traditional postscenario debriefing in that it moves the debriefing to occur within the scenario. In RCDP, the scenario gets paused if participants act incorrectly, and they receive immediate feedback and correction from a facilitator. The case then "rewinds," the participants can practice the action again, this time doing it the "right way." The scenarios progress in difficulty upon mastering a skill, built on previously mastered skills.[12][13]

Advocacy inquiry is a technique where the facilitator first advocates their observation of an action or behavior and then inquires about the participant's frame of mind relative to the action.[10] 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 (the facilitator advocates their observation). I was worried about the potential of you getting bitten by the patient during your attempt to open the mouth (shares their point of view). I was curious about 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 another common debriefing method in medical simulation.[10] 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.

Clinical Significance

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 examining the efficacy and feasibility of telebriefing as an alternative to in-person debriefing found that telebriefing was rated slightly lower than in-person debriefing but was still 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.[1] 

The authors also report the possible reasons 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.[1] In addition to the limitations mentioned above, technological and time-zone discrepancies can also provide challenges to implementation.[7] 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 void of patient risk.[8][14] 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 believes simulation is arguably the most prominent innovation in medical education over the past 15 years.  Simulation in medical education and training can revolutionize healthcare education, healthcare delivery, and quality improvement initiatives and address patient safety issues if appropriately utilized and integrated into the educational and organizational improvement process.