Introduction

The most important component of simulation-based learning is debriefing; this is the opportunity participants have to reflect on events that have happened and to modify their behavior as a result.[1] Trained facilitators generally guide participants through this reflective process and seek to identify and close knowledge gaps through discussion.[2] The debriefing may occur at the end of the simulation (post-event debriefing) or periodic stopping points during a simulation (micro-debriefing). While some studies have looked at peer-debriefing and self-debriefing, most debriefing is conducted by a trained faculty member. These facilitators may debrief verbally or with the assistance of a video review. Video-assisted debriefing (VAD) can help to structure debriefing following simulation. There are pros and cons to using video during debriefing, as described here.

Function

There are several reasons for recording in the health care environment. Some clinical sites already video their actual resuscitations and perform debriefings of actual patient care.[3] Others have used in situ simulations with video-assisted debriefing (VAD) to focus on key portions of trauma management to improve overall trauma care and received positive feedback from participants.[4]

Traditional simulation sessions may also be recorded. Sometimes, these recordings are not reviewed by the participants. In these cases, access to the recording of simulations or actual resuscitations may aid research or drive subsequent quality improvement projects.[5][6][7] Some users advocate reviewing videos of simulation and subsequent debriefing for quality control, specifically as a means of monitoring session quality and facilitator debriefing skills.[6] Most commonly, however, simulation sessions are recorded for the primary purpose of using them during post-event debriefing.

Proponents of video-assisted debriefing (VAD) cite several benefits with this method. One frequently cited benefit is obtaining an objective record of what happened during the simulation.[1] Rather than relying on potentially faulty recall of either the instructor or the participants, a video clip can improve debriefing by replaying segments exactly as they happened and limiting of recall bias.[8][9][10] A debriefing without this clear record may get derailed by participants arguing over what they remembered having occurred. Participants cite a concern for “unfulfilled learning needs” in debriefings without video, as feedback may be general and unconstructive without the ability to pinpoint a certain event or behavior.[9]

The second benefit of VAD is the opportunity for learners to observe their performance from a different perspective. It may highlight the performance of either an individual or the whole team and allow for reflection of communication and teamwork during simulated events.[11][12] This process enables self-reflection in so far as participants have the opportunity to watch their behaviors from an outside perspective, which then enables them to identify previously unknown deficiencies or quirks, and perhaps it may help increase their motivation for change.[9][13] They may also gain improved confidence by objectively watching their successful performances.[13] The experience may help participants become more receptive to feedback, since analyzing something observed onscreen may be felt as less personal and may lead to reduced learner defensiveness.[9] 

The third benefit of VAD is that it may help fill in learning gaps. There is data to suggest that video-assisted debriefing improves subsequent performance in both teams and individuals.[11][13] Most of the literature has addressed the performance before and after video debriefing; this has been in contrast to comparing video-assisted debriefing (VAD) versus verbal-only debriefing (VD). One study that compared VAD to VD directly has found that participants who received video debriefing, improved CPR quality delivery more effectively than did those who received only verbal feedback.[14]

Although there are potential benefits to VAD, there are several concerns as well. Competent technical support may help prevent most audio/visual- or equipment-related problems. However, realistically speaking, there is no way to eliminate the risk of these issues.[9]

A second concern with the use of VAD is the potential threat to psychological safety. Much emphasis is placed on the concept of the learning environment being a “safe container” for learning.[15] While a facilitator may attempt to create a safe simulation learning environment, the presence of a recording instrument may serve to undermine this goal. Specifically, psychological safety may be an issue, since learners may fear that videos will be shown outside of class.[9]

Additionally, concerning the use of VAD, while some studies have suggested mild effectiveness, others have found mixed efficacy. The same early study found no difference in VAD versus VD for subsequent improvement in nontechnical skills. They also found a trend toward lower post-test scores among those participants who had received VAD.[16] The study’s authors speculated that this might have been due to “information overload” in the video, which appeared to have resulted in learners being less attentive to facilitator-mediated feedback.[16]

Opponents of VAD cite the time spent on video review could have been applied to a complete verbal debriefing opportunity. Finally, incorporating a video review process adds the additional layer of recording equipment expenses.[9]

Results on the direct comparison between VAD and VD are mixed.

One early study addressed anesthesia residents performing nontechnical skills. The participants who had no debriefing showed no improvement in subsequent simulations. The participants who had either VD or VAD demonstrated improvement, but neither group improved more than the other.[16] Similarly, there was no significant difference between the two debriefing methods in the debriefing of a group of nursing students either.[17]

Other authors have also failed to demonstrate significant differences between VD and VAD for time-based skills, or overall improvement.[18][19] While most studies comparing the efficacy of VD and VAD have focused on single learner groups (resident physicians, nursing students, etc.), the trend toward similar results for VD and VAD was observed among mixed learner groups, as well.[19]

Others have found that video did appear to provide more information than only a single perspective could.[20]

Issues of Concern

While the goal of simulation-based education is better patient care, the learning experience is also important. The use of video in a debriefing did not appear to change the learner's perception of the importance of the simulation session when compared with a debriefing that had no video review.[11] It may, however, have elicited other feelings.

Fear (stress/discomfort) may have been one consideration from the learner's perspective. Some learners have described the process of watching themselves in a VAD as an emotional roller coaster. They seemed to have feared the judgment by others and maybe felt defensive. Yet, at the same time, they expressed both desire and appreciation of feedback and appeared satisfied with the overall experience.[9] Many initially described the experience of feeling nervous when they heard that the simulation would be recorded. However, they received assurance that most participants would "get over it" as the scenario progressed.[9] Other researchers have reported a reluctant segment of learners who felt VAD would make them feel humiliated or tried.[11] Some researchers urged that desensitization to the video process might help address learner discomfort.[9] Therefore, playback segments should be carefully selected. A clarification may be provided on what the debriefer would like the learners to focus on. 

Other learners may have had a more positive experience as a result of VAD. Although Ha, et al. found a group of learners whom they classified as having a reluctant view (namely the group that felt VAD made them feel humiliated and tried), they identified two other learner groups with more positive viewpoints. These they classified as holding a strategic view, who felt VAD aided in their self-reflection, or a forward view, who felt VAD improved their self-confidence.[11]

Continuing Education

VAD facilitators have the added responsibility of choosing appropriate video clips. The actual professional title of the debriefer is not as important as attention to general high-quality debriefing skills. One study has suggested that participants prefer faculty-led VAD to peer-led VAD. Indeed, they indicated that they trusted the knowledge and feedback skills more.[9] A subgroup of those participants thought that faculty-led VAD might be superior for new skills, but that peer-led VAD may be better for skills in which the learners were already proficient because they would not be as stressed watching their performance as they would be when they were watching with the instructor.

There is no consensus on VAD elements or best practices.[9] Some have recommended watching selected clips only and allowing participants to comment on their performance before the instructor comments.[16] Others have suggested allowing viewing of the entire video. Even learners themselves are divided on which method they prefer.[9] A survey of expert debriefing facilitators has suggested using a few clips only, with pre-briefing before viewing the entire video. This variation in practices has led to some having suggested more uniformity with VAD, spelling out the phases along with a debriefing plan for this form of debriefing.[21]

Clinical Significance

Simulation without debriefing is ineffective in creating change.[16] How that debriefing is conducted, whether by employing VD or VAD, appears to make no significant difference.[22][23] Both verbal and video-assisted debriefing can help elicit behavior changes and meet learning outcomes.[9] What matters more is the communication skills of the debriefer.[9] Although VAD has been used successfully and may be preferred in some circumstances to VD only, there is insufficient data to indicate that it is superior to verbal debriefing alone.[21] However, thoughtful and strategic use of video can improve learning during debriefing.

Pearls and Other Issues

1. Benefits of VAD include an objective record of events, the ability to gain an outside perspective, and effectiveness in closing learning gaps.
2. Challenges of VAD include adding potential distractions, a potential threat to psychological safety, mixed learning outcomes, time constraints, and cost.
3. The effect of VAD on learner experience is similarly mixed.
4. While VAD may be preferable in some situations, there is no definitive evidence to suggest it is a superior method of debriefing.

Enhancing Healthcare Team Outcomes

The ultimate goal of simulation is to improve patient care. Debriefing is a critical component of healthcare simulation, regardless of whether the primary learning objective is knowledge transfer or the development of teamwork and/or communication skills. The use of VAD may contribute to a high-quality debriefing, but it is not a necessary component.

Participants may derive benefit from reviewing their performance on videotape and discussing it during debriefing. VAD provides the opportunity to evaluate team processes and offers support to improve teamwork.[12] Regular video-assisted team-based in situ training with video debriefing has shown a significant reduction of resuscitation time in the emergency department.[4] Postoperative video debriefing has also been shown to reduce technical errors during laparoscopic surgery.[24] This practice has also been reported to improve adherence to guidelines during resuscitation.[25]