Debriefing and feedback

Debriefing and feedback are key components of every simulation encounter. Even though they might sound like synonyms they are the names of the two distinct types of information exchange during or after simulation activity.

The Society for Simulation in Healthcare (SSIH) and the International Nursing Association of for Clinical Simulation and Learning (INACSL) have slightly different definitions of these terms but all of them are included in the Healthcare Simulation Dictionary, Second Edition published by the SSIH.

Feedback (definition)

- (noun) An activity where information is relayed back to a learner; feedback should be constructive, address specific aspects of the learner’s performance, and be focused on the learning objectives. (SSIH, 2019)

- Information transferred between participants, facilitator, simulator, or peer with the intention of improving the understanding of concepts or aspects of performance. Feedback can be delivered by an instructor, a machine, a computer, a patient (or a simulated person), or by other learners as long as it is a part of the learning process. (INACSL, 2013)

Debriefing (definition)

- (noun) A formal, collaborative, reflective process within the simulation learning activity. (SSIH)

- (noun) An activity that follows a simulation experience and led by a facilitator. (SSIH)

In a nutshell, debriefing is a process used to reflect on the work performed during an encounter while feedback is a tool of the debriefing to convey certain information.

Feedback could be informally divided into the following types:

1. positive (e.g. the arrhythmia was correctly recognized in a timely manner) which articulates what was done well

2. neutral (e.g stating that the breath sounds are absent over the left lung when a learner performs an endotracheal intubation) that just constates the fact

3. constructive (e.g. the chest compressions were interrupted for longer than ten seconds) mentions something that needs to be improved.

If feedback is used during the simulation encounter, it is highly recommended to keep all feedback neutral to keep the learners engaged and save all positive and constructive feedback for the after the activity debriefing. Feedback is important for deliberate practice whose goal is achieving mastery of a given skill or competency. Without positive and constructive feedback learners would lack guidance for improving. It is important that feedback is descriptive, timely, and relevant.

As it has been mentioned before, debriefing is a process of reflecting on the activity with the goal to determine underlying cognitive frames that the instructor and learners have, analyze and modify them to improve learners’ performances. Cognitive frame is a system of beliefs, concepts and attitudes that determines one’s behavior in a given situation. Most often debriefing takes place after a simulation activity but there are exceptions such as Rapid Cycle Deliberate Practice (RCDP) simulation that uses debriefing during the encounter. There are various debriefing techniques used in simulation. In this module we will review the essential aspects of the most frequently used debriefing techniques. The suggested reading section of the module includes a list of literature for those who are interested in the in-depth knowledge of the subject.

Facilitator-Guided Post-Event Debriefing: “Let’s talk about the case …”

The Facilitator-Guided Post-Event Debriefing (FGPED) is one of the most frequently used types of debriefing.

Promoting Excellence and Reflective Learning in Simulation (PEARLS) is a FGPED technique developed by Eppich and Cheng. It is organized of four distinct phases:

1. Reactions.

2. Description.

3. Analysis.

4. Summary.

During the “Reactions” phase learners identify the important to them aspects of the encounter. This creates a suggested list of learning objectives created by learners. In the “Description” phase the facilitator summarizes the simulation encounter into one- or two-sentence statement from a clinical point of view, e.g “The scenario was a case of a meningitis complicated with septic shock and ARDS.” The “Analysis” phase is the largest part of the debriefing. Its purpose is to:

1. identify learner’s frames (beliefs, concepts, attitudes etc.)

2. identify knowledge/skills gaps

3. provide information to close the gaps

During the “Analysis” phase the goal of the facilitator is to identify the reasoning behind the learners’ behaviors observed during the encounter, reaffirm the positives and correct the misconceptions. The key debriefing instrument in this phase is asking guying questions and lead the group of learners through the discussion. The more learners are engaged in the discussion the better would be the results of learning. The following techniques can improve obtained knowledge retention:

1. processing information in clusters

2. summarizing information for each cluster

3. repeating the summary if needed

4. applying the concept to a different comparable scenario

Teaching during the “Analysis” phase could be either learners or educator guided which is determined by the amount of the learners’ insight into the scenario and its concept. For the topics where the educator feels that learners have limited experience, the educator needs to assume the leading role. The “Summary” phase of the debriefing wraps up the encounter and prepares the learners to apply acquired knowledge and skills in the other clinical situations. It also helps with transferring new knowledge and skills from simulation to patient care. Effect of this technique depends a great deal on the ability of the educator to create an emotionally safe environment for the learners so the challenges of the encounter are perceived as a stimulus for engagement (e.g. “We will beat the simulator!”) rather than a threat to the learners’ professional egos. Setting clear expectations and ground rules of engagement, a non-judgmental atmosphere, and supporting attitude from the educator are essential for productive simulation encounter and debriefing.

Plus-Delta debriefing technique: “What have you done right and what would you do differently?”

Plus-Delta is a non-judgmental way to say, “Please tell me what you did right and what you did wrong.” Instead of saying “wrong,” the instructor says, “What would you do differently?” In mathematics, the Greek letter “delta” means the “difference,” thus, the name, Plus-Delta. This is the most straightforward method of debriefing, though it has some disadvantages.To use the plus-delta method, an instructor needs to have a comprehensive checklist of the important actions that the learners need to take during a simulation encounter. These important actions are frequently called as critical performance indicators (CPI). (For example, the checkboxes in the checklist that an examiner uses to grade students’ performances during an OSCE examination are actually the case-specific critical performance indicators! It is just a pretentious term for a little checkbox!) The instructor and the learner discuss each CPI that was performed correctly and each CPI that was either not performed or performed incorrectly.

The benefits of the plus-delta debriefing technique are that it is:

1. least time-consuming method

2. straightforward and unambiguous

3. requires least training for the facilitator

The main disadvantage of the plus-delta debriefing technique that it does not always allow to explore learners’ frames and focuses more on the learning objectives and outcomes than on the learner.

Debriefing with Good Judgement: “I will judge you but I’ll do it with respect!”

The name of this debriefing method stems from the idea that debriefing could be judgmental or non-judgmental. Dr. Rudolph and her collaborators called this method a combination of “rigorous feedback and genuine inquiry.” Debriefing with Good Judgement (DGJ) has three primary components:

1. Conceptual framework to identify salient mental models that guided learners’ actions.

2. Debriefing stance (combines empathy to the learner with the need to provide evaluative judgment).

3. Communication technique to enact the debriefing stance.

The goal of the first component is to identify why the learner acted in a certain way rather than the other. Knowing the reasons for a behavior would allow for a better way to correct it if needed. Before beginning a discussion of the debriefing stance, we need to briefly review judgmental and non-judgmental approaches to debriefing.

The judgmental approach, also known as “shame and blame” one, makes:

1. clearly identifies a mistake

2. poses the instructor as the holder of the truth, “I am right, and I will set you straight”

3. poses the learner as responsible for the mistake, “You are wrong.”

It does not matter how harshly or softly this method is used, judgmental approach places the responsibility for the mistake into the hands of the learner who feels guilty with no guilt (e.g. “You told me that simulation is the place to learn from own mistakes, and now you blame me for making the mistakes! I am still learning!!!”). The only benefit of the judgmental approach that the error is apparent.

The non-judgmental approach attempts to avoid blaming but still carry the message across. Some educators believe that there is no such a thing as a non-judgmental approach. They believe that the only difference between the two is that in the non-judgmental approach the subject is sugar-coated, direct terms are substituted by social hints (beating around the bush), or the critical points of discussion are avoided. This method of debriefing is often more detrimental to the learners because they have a feeling that there was something wrong with their performance and no one was brave enough to tell them what exactly was wrong (e.g. “Was it so bad that they afraid to bring it for the discussion?”). Often, the learners are left in doubt what exactly was done wrong and can draw wrong conclusions leading to faulty learning. The actual message to the learner is still the same as with the judgmental method of the debriefing, “I am the instructor, I have the full picture. I am right and you are wrong. It is my job to hand over the correct knowledge and behavior to you, the trainee.” In the “good judgement” debriefing, besides creating a psychologically safe environment and extending the focus of debriefing to include not only the trainee’s actions but also his or her frames, assumptions, and knowledge, the instructor’s perception of the simulation encounter becomes part of the subject of the debriefing. Thus, the “good judgement” technique values the instructor’s expert opinion and at the same time values the unique perspective of each learner. As it has been mentioned before, the “good judgement” debriefing technique requires extensive training and practice. We suggest that at this moment the learners of this course just get familiar with the existence such a technique and learn how to use it as their simulation educator’s experience grows. In 2020, a Pillar 3 student at the University of South Dakota Sanford School of Medicine, Bogdan Anton, has intuitively develop an effective combination of the Facilitator-Guided Post-Event Debriefing and the Plus-delta debriefing techniques. He used the FGPED technique for the major portion of the debriefing saving the Plus-delta for the students to wrap-up the case discussion.

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