Monday, September 21, 2020
by SimGHOSTS Board member Dr. Scott Crawford
The Society for Simulation in Healthcare Dictionary defines debriefing for simulation as “A formal, collaborative, reflective process within the simulation learning activity.”1 This process is why simulation is believed to work so well as an educational tool. When conducted properly, a facilitator is able to help learners critically assess their actions, understand why they performed the way they did, when they did, and be able to take their knowledge outside of its original context and apply concepts in new and unique situations. The facilitator assists the learner to develop this new knowledge through guided reflection, and this process is distinct from classical teaching through a lecture. While transfer of direct knowledge can and still must occur, it is referred to as feedback and should be constructive and kept to a minimum in this setting.
Debriefing is a complex process, and to perform it correctly takes practice, patience and an open mind. One concept that is difficult to understand is that what the learners experience is never wrong. Their actions can be incorrect based on their interpretation of information, or their assumptions may be falsely supported, but each individual’s perceptions cannot be incorrect because that is how they experienced the situation. This is why the setting for debriefing becomes important. Learners may feel exposed or placed under scrutiny during simulation, but it is their ability to candidly share their thoughts and rationale for their actions that will help them find areas for improvement. They must feel psychologically safe and supported in order to participate fully in these sessions. It is therefore important to explain the expectations of the simulation experience and the plan for debriefing in advance. This will help to set the stage for a learning environment where it is safe to make mistakes, show deficiencies and be able to identify and fill these gaps. Individuals will be more likely to share their thoughts if they do not feel that there will be negative consequences for not knowing, and have time to process and understand what information they used to determine their course of action. This may not be immediately clear to either the learner or the facilitator, and careful probing can bring to light what led to the outcome, whether positive or negative.
Because perceptions cannot be wrong, but inconsistencies in reproducing the physiology of human disease in a simulated environment are inevitable, introducing the concept of the “Fiction Contract” should be put forth up front. This is the explicit acknowledgement of the limitations of the simulated environment, while still asking learners to immerse themselves into this world with the same care and tact as they would in a real clinical setting. In return you can offer your best efforts to make the simulation as close to lifelike as feasible. With this contract established, the facilitator and learner can engage in the simulation on common ground.
The learning theory on which simulation is based is from a textbook by David Kolb originally published in 1984. In it, Kolb reviews many models of learning and summarizes finally that “Learning is the process whereby knowledge is created through the transformation of experience.”2 This statement emphasizes that knowledge is created; it is not a fixed entity to be transferred. This process is depicted in Figure 1. The graphic outlines how your experiences shape your understanding and conceptualization through perception, while the ability to go from watching to doing reflects your processing of learning. Each quadrant is interconnected, and a masterful facilitator can help guide you from one stage to the next. Experimentation and experience occurs during the simulation activity, while debriefing is in the realm of observation and conceptualization.
Figure 2 Kolb Learning Theory
A facilitator’s debriefing abilities can and should be reviewed to assist with development of this skill. The DASH (Debriefing Assessment for Simulation in Healthcare) is one such tool that can help. This is a six category assessment that can be used to assess how the facilitator performs in the following areas3:
• Establishes an engaging learning environment
• Maintains an engaging learning environment
• Structures the debriefing in an organized way
• Provokes engaging discussion
• Identifies and explores performance gaps
• Helps trainees achieve or sustain good future performance
It is recommended that a grader be familiar with the grading form and its instructions prior to use. An online version is available here (https://harvardmedsim.org/debriefing-assesment-simulation-healthcare.php).
Now that you know what debriefing is and why we do it, click here for a review of styles that can be used to help you guide your debriefing process.
1. Lopreiato JO, ed Healthcare Simulation Dictionary. 2016.
2. Kolb D. Experiential Learning: Experience as the Source of Learning and Development. 1984; Vol 1 Englewood Cliffs. In: NJ Prentice-Hall.
3. Brett-Fleegler M, Rudolph J, Eppich W, et al. Debriefing assessment for simulation in healthcare: development and psychometric properties. Simulation in Healthcare. 2012;7(5):288-294.