UCSF Center for Faculty Educators Kanbar Center for

UCSF Center for Faculty Educators & Kanbar Center for Simulation Sandrijn van Schaik, MD Darren Fiore MD Mehran Hossaini, DMD 2015 Debriefing Scenario. Based Simulation Sessions Models and Approaches

Workshop Objectives • Explain the role of debriefing in simulation • Differentiate among three different approaches to debriefing. • Apply commonly used debriefing skills. • Manage basic pitfalls frequently encountered in debriefing.

Roadmap • Debriefing: styles and approaches • Group discussion: experiences • Small group activity: video examples and practice • Summary and evaluation

Debriefing: A Conversation After Simulation • A process in which a team reexamines an encounter to foster development of clinical reasoning, critical thinking, judgment, communication and teamwork through reflection. • Methodically review what happened and why. • Clarifies and consolidates learning gained from an experiential exercise.

A Critical Aspect of Simulation “In simulation, knowing how to debrief the learner’s experiences is as critical as creating scenarios and selecting the correct mannequin. ” J Perinat Neonat Nurs. Vol. 24, No. 4, pp. 302– 309

6 Theoretical Framework Am J Surg. 2015 Jan; 209(1): 12631.

The Essence of Debriefing • Debriefers make an implicit comparison between desired and observed performance. • Performance gap can be big or small. • Describe assessment of this gap and inquire about its origins. • Explore “frames. ” • Improve poor and reinforce good performance.

Debriefing: Aims • Stimulate self-reflection. • Share ideas, raise awareness of alternate approaches. • Teach specific skills: procedural, communication, cognitive, teamwork. • Behavior change.

Pair-share exercise • What challenges have you had/do you anticipate in debriefing? 10

When to Debrief • After a simulation session, learners are emotionally charged. • They analyze and criticize their performance. • Validation of excitement / harnessing energy… • Focusing it in a productive manner. – Draw links between behavior and outcome; more likely to change future behavior. • Consider changing location. – Learners move from state of action to reflection.

Phases of Debriefing Reaction/Decompression • Venting, emotional • Fear of judgment • Permit these reactions • But shift to reflective discussion Analysis/Reflection • Most important part • Instructor uncovers • Explore learners’ mental frameworks to provide • Helps build alternates to insight into observed improve performance gaps Summary • Reinforce learning objectives • “Teaching riff” • Provide key take home points

Role of Facilitator(s) • Make it safe – Create environment of trust and support – Neither overly harsh nor falsely kind • Make it stick – Promote reflective analysis • Engage team members in debriefing process – Make it last Am J Surg. 2015 Jan; 209(1): 12631. • Elicit commitment to change • Identify performance gaps/areas of improvement

Approaches to Debriefing • Judgmental • Nonjudgmental • Debriefing with “good judgment” Simulation in Healthcare. 2006; 1(1): 4955.

Debriefing with Good Judgment • Cornerstone: Assume the best intentions of learners, regard mistakes as a mystery to be analyzed rather than a crime to be punished.

Debriefing with Good Judgment • Allows for evaluative judgment while respecting learner. • Premise: Uncover mental frameworks that guide action, being employed by learners AND debriefer. • Debriefer is aware of own framework, because this guides what they think should have happened. • Debriefer ensures safe yet reflective environment, allowing learners to be more open to receiving alternative frameworks.

Debriefing leads to new frames Debriefing changes later actions Frames invisible Actions Results observable Frame: “I must have a pulse oximeter attached to know how the patient is breathing. ” Action: Frantic search for a pulse ox. Result: Pt desaturates and descends into hypoxia. Alternate Frame: “There are more reliable ways to assess breathing than pulse ox, like chest rise, lung auscultation, or color. ” Action: Ignore missing pulse ox and assess clinical parameters of respiration. Result: Recognition of no chest rise, no breath sounds, and starting oxygen therapy.

Individual frames Made visible through debriefing Unified actions 19

Debriefing with Good Judgment • Pair advocacy (observation, statement) with inquiry (question). • Formula: – Observation (I noticed that…) – Reasoning or concern (It seemed to me that…) – Question (How did you see it? ) – Follow-up with teaching riff.

Example 1 Observation Reasoning or Concern Question “I noticed that you stepped away from the patient to look for a pulse oximeter…” “…And it seemed to me that there were alternate means to assess respiratory status…” “…I was wondering what your thoughts are? ” Judgmental “I was shocked that you walked away to look for a pulse oximeter for 90 seconds while the patient desaturated!” Non-judgmental (guess what I’m thinking approach) “So, what was the patient’s saturation when you went to look for a pulse oximeter? ”

Example 2 Observation Reasoning or Concern Question “I heard you say ‘let’s not call a code yet’ at one point…. ” “…I was concerned that the patient was deteriorating rather quickly…” “…Help me understand how you decided that? ” Judgmental “I really would have called a code when the patient was deteriorating so quickly – I’m not sure why you hesitated. ” Non-judgmental (sandwich approach) “I really liked how you delegated critical tasks. Next time, it might be beneficial to get more help in the room by calling a code. But I liked that took charge – it was clear to me that you were leading the code. ”

Debriefing Using Advocacy-Inquiry Observation (Advocacy) Reasoning or Concern (Advocacy) Question (Inquiry) I noticed that… I liked how you… How did you see it? I saw that… It seemed to me that… I was wondering what your thoughts are? Anyone else have a thought? I heard you say… I was concerned that… I got the impression that… Help me understand how you decided that. I’m curious how you felt about that. In there anything you would do differently next time? Adapted from: Anesthesiology clinics 25. 2 (2007): 361 -376.

Some Practical Debriefing Tips • Create a safe environment: set ground rules • Take notes while observing simulation • Link debrief to simulation and refer to 23 specific events that occurred. Choose wisely, with learning objectives in mind. • Use first person. – “I observed…” – “I am concerned because…” • Be genuinely curious; aim to discover learner’s perspective.

Some Practical Debriefing Tips • Use short, open‐ended questions. – “I am curious how you see it? ” – “What was happening at that point? ” – “How did you experience that? ” – “I wonder why? ” • Provide individual and team-oriented feedback. • Reflection back to the group. • Maintain silence; don’t dominate discussion.

Use of Video NO evidence that it is better PROS: • Elimination of recall bias. • Objective measure of the learner’s actions. • No uncertainty (positive or negative). • Pause, instant replay. • Opportunity to see self from different perspective. – Participant --> observer • Data source (evaluate systems errors, time-sensitive events, teamwork).

Use of Video: CONS • Intimidating • Distracting • Technical issues • Personnel, time • Cost • Consent • Possibly changes learners’ behavior (Hawthorne effect)

Evaluation Parameters for Debriefers Parameters Goals Length of scenario compared with length of DB is approximately 3 times the length DB of the scenario Length of time after scenario ends to when 5 min or less DB begins # of learning objectives covered during DB Key learning objectives covered (2 -4) Number of debriefer questions compared to > number of questions to statements, number of open-ended depending on DB strategy. > openquestions compared with yes/no questions ended questions than yes/no questions Number of participant responses compared Participant vocalizations compared to w/ number of statements/questions of debriefer , at least 2: 1 or 3: 1 debriefer Length of videotape segments played Adapted from Center for Advanced Pediatric and Perinatal Education Play segments most impt to discussion of learning objectives (not whole tape)

Evaluating Debriefers: DASH Elements Establishes an engaging learning environment Maintains an engaging learning environment Structures the debriefing in an organized way Provokes engaging discussions Identifies and explores performance gaps Helps trainees achieve or sustain good future performance

Video Examples and Discussion • What was done well? • What could be improved? • How might you do things differently? – Practice using advocacy-inquiry

Reflection • Goal of simulation is teamwork, objectives center around teamwork skills such as role distribution, direct communication, closed loop communication • What do you notice? • How do you think the nurse and resident feel after this simulation? 31

Small Group Activity • Groups of 4 • Practice debriefing: 1 debriefer, 2 team members, 1 observer • Focus on specific language/words that you might use

Summary • Debriefing is the most important part of a simulation exercise; it enhances learning opportunities and stimulates self‐reflection. • Debrief in three phases: reaction, analysis and summary. • Debriefing with good judgment aims to uncover learner’s frameworks and is performed using advocacy statements paired with inquiry.

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