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Introduction to debriefing
Roxane Gardner, MD, MPH, DSca,b,c,d,n
a
ARTICLE INFO
a b str a c t
Debriefing is a lynchpin in the process of learning. As a post-experience analytic process,
Keywords:
Debriefing
learned into ones cognition and consciousness. Debriefing provides opportunities for
Feedback
exploring and making sense of what happened during an event or experience, discussing
Healthcare simulation
what went well and identifying what could be done to change, improve and do better next
Simulation-based medical
education (SBME)
that include a brief review of its origin, the structure and process of debriefingspecifically
in the context of simulation-based medical education, and factors that facilitate effective,
successful debriefing. An approach to debriefing immediately after real clinical events will
be presented, as well as an evidence-based approach to evaluating debriefing skills of
healthcare simulation instructors.
& 2013 Elsevier Inc. All rights reserved.
1.
Introduction
2.
Correspondence address. Center for Medical Simulation, 65 Landsdowne St, Cambridge, MA 02139.
E-mail address: rgardner1@partners.org
0146-0005/13/$ - see front matter & 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1053/j.semperi.2013.02.008
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3.
The role of debriefing in healthcare
simulation
It was during the late 1980s that David Gaba, an anesthesiologist, translated aviations crew resource management
into critical medical event management, later shortened to
crisis resource management.26 At the same time, Gaba et al.
reintroduced fully interactive human patient mannequin
simulators and used them for training anesthesiologists in
simulated critical incidents within a comprehensive, simulated anesthesia environment.27,28 Gaba, regarded as the
grandfather of crisis resource management and medical
simulation, highly values debriefing as an integral part of
the process of any experiential-learning technique.26 Gabas
innovations in training anesthesiologists were soon adopted
by others in the field.29 Crisis management and medical
simulation-based education has since been adopted across
the health professions and disciplines.3033 Debriefing and
feedback remain fundamental elements of simulation-based
learning.34,35 According to Dieckmann et al., regardless of
simulator usage, the post scenario debriefing is important to
maximize learning and facilitating change on an individual
and systematic level.35 Such change may involve modifying
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4.
Adults learn through experience, by processing it and assimilating lessons learned into their world view. The more
relevant the experience is toward achieving personal or
professional goals, the more meaningful such learning is
regarded.20 Kolbs theoretical framework of experiential
learning is a cornerstone in the educational foundation of
simulation-based education22 (see Fig. 1). In Kolbs cyclical
model, learners enter through active engagement in a concrete experience.
The experience is followed by a period of reflective observation. Through self-reflection and facilitated discussions,
learners can conceptualize, make sense and gain insight
toward a more informed understanding of the event and
how this may apply to future situations. The final step in the
cycle is experimentation, the phase whereby learners try out
the new approach or skills in a future simulated or real event;
and so the cycle continues. Kolbs experiential-learning cycle
in the context of simulation-based education embodies
reflective practice, reflection-in-action and reflection-onaction.3942 Reflective practice helps build self-awareness of
unconscious cognitive routines and emotional reactions.
Through reflective practice, learners can view situations in
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5.
Structure and process of debriefing in
simulation-based medical education
A sentiment shared among simulation educators is that
simulation is a good excuse to debrief. There is no universally
accepted gold standard approach to debriefing in simulationbased medical education (SBME). However, key structural
elements of debriefing have been identified by Lederman that
includes, (1) the debriefer, (2) participants to be debriefed, (3)
an experience (simulated case), (4) the impact of the experience, (5) recollection, (6) report, and (7) time.2 (see Table 1.)
A few elements are straightforward and require no further
elaboration. Item four, the impact of the experience, relates
to the emotional engagement, be it stressful, anxietyprovoking or elating; and the relevance of the experience to
the learner. Item six may range from a formal report to
completing a survey or questionnaire; and item seven refers
to the time that passes between the end of the experience
(simulated case) and onset of the debriefing. Debriefing in
SBME most often takes place immediately after a simulated
Table 1 Key Structural Elements in Debriefing 2
Fig. 1 Kolbs learning cycle.22 In Kolbs experientiallearning cycle, a learner enters through an experience,
reflects on that experience, analyzes and processes its
meaning, and then tries a different approach in a similar,
future situation based on their new understanding.
(Modified from Kolb.22)
1.
2.
3.
4.
5.
6.
7.
Debriefer
Participants to be debriefed
An experience (simulated case)
The impact of the experience (simulated case)
Recollection
Report
Time
Seven key structural elements of debriefing identified by Lederman in 1992. (Modified from Lederman.2)
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Process of debriefing
7.
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8.
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9.
10.
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11.
!
!
!
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12.
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13.
event
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performance or systems. Teammates then take turns identifying what specifically can be done to improve and how to go
about it.
Depending on the circumstances and clinical outcome, a
more formal review of events may be needed such as referral
to quality assurance or risk management for a formal rootcause analysis.
Debriefs conducted in real-time will more likely be selfdirected and not led by an external facilitator or trained
debriefer, especially after a routine event with a good outcome. However, a moderator can be self-declared or designated by role, such as the team leader, nurse leader or the
event manager, whose primary task is to move the conversation along if it is getting stalled, circular or unproductive. If a
moderator is designated by role then specific training in
debriefing can be arranged. With or without a trained
debriefer, a simple model to follow is the plusdelta debrief
(see Table 3).
The plusdelta debriefing model is based on the approach
designed for commercial aviation and modified for healthcare.61
This model is quick, convenient and easy to use as an afteraction review. The plus column indicates things that went
well and the delta column indicates things that need to be
changed and how to change them. The key is to have teammates be specific. The plusdelta debriefing approach tends to
focus on actions and system-related issues and not frames.
In summary, debriefing allows us to learn what went well
and what did not go well so that individuals within the
organization can learn how to work together better as a
team. No detail is too small to identify if it leads to improvement in the system. With practice and consistency, debriefing
can become a habit and more natural and comfortable after
an urgent event or emergent one with a poor outcome.
Debriefing after each event, whether routine or not, facilitates
cultural change necessary to talk more openly about team
performance, and learn from near misses, errors and
successes.62,63
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14.
Assessing skills of debriefers in
healthcare simulation
15.
Conclusion
Plus
Team identifies what specifically went well
!
!
!
Inga stated the situation clearly out loud for the team and asked for help
early: We have a shoulder dystocia, get help
Edward closed the loop about where to apply the suprapubic pressure
Marie kept track of time and announced it out loud to the team
D
Delta
Team identifies what specifically to change and do better next time
!
!
!
The plusdelta debriefing model, adapted from aviation for use in healthcare settings, can be performed in 5 min or less by the team
immediately after any routine or critical event. Items identified can be used to facilitate organizational change. (Modified from Klair.61)
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11.
12.
13.
14.
15.
16.
Acknowledgments
17.
18.
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20.
21.
1. Lederman LC. Debriefing: a critical re-examination of the
post-experience analytic process and implications for effective use. Simulations Games. 1984;15:415431.
2. Lederman LC. Debriefing: towards a systematic assessment of
theory and practice. Simulations Games. 1992;23(2):145160.
3. Rall M, Manser T, Howard S. Key elements of debriefing for
simulator training. Eur J Anaesthesiol. 2000;17:516517.
4. Morrison, John E, Meliza, Larry L. Foundations of the After Action
Review. Alexandria (VA) Institute for Defense Analyses (US).
/http://www.dtic.mil/cgi-bin/GetTRDoc?Location=U2&doc=
GetTRDoc.pdf&AD=ADA368651S; 1999. Accessed 11.11.12.
5. Shalev A. Historical group debriefing following combat. U.S. Army
Medical Research & Development Command, Fort Detrick,
Frederick (MD). Final Report. May 1, 1993. /http://www.dtic.
mil/cgi-bin/GetTRDoc?AD=ADA267287S. Accessed 14.11.12.
6. van de Ridder JM, Stokking KM, McGaghie WC, Ten Cate OT.
What is feedback in clinical education? Med Educ. 2008;42(2):
189197.
7. Headquarters, Department of the Army. A Leaders Guide to
After-Action Reviews. TC 25-20. Washington (DC). /http://
www.fireleadership.gov/toolbox/after_action_review/Leaders_
Guide_to_AARs.pdfS; 1993. Accessed 10.11.12.
8. Lauber JK. Cockpit resource management: background and
overview. In: H.W. Orlady, H.C. Foushee, ed. Cockpit Resource
Management Training. Proceedings of a Workshop Sponsored by
NASA Ames Research Center and the U.S. Air Force Military Airlift
Command. San Francisico, CA: NASA Conference Publication
2455; 1987: 5-15 [May 68, 1986].
9. Helmreich RL, Foushee HC. Why crew resource management?
Empirical and theoretical bases of human factors in aviation.
In: Wiener EL, Kanki BG, Helmreich RL, ed. Cockpit Resource
Management. San Diego: Academic Press; 1993.
10. Diehl A.E. Does Cockpit Management Training Reduce Aircrew Error? Paper presented at the 22nd International Seminar International Society of Air Safety Investigators; 1991
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
173
174
SE
M I N A R S I N
E R I N AT O L O G Y
33. Issenberg SB, McGaghie WC, Petrusa ER, Gordon DL, Scalese
RJ. Features and uses of high fidelity medical simulation that
leads to effective learning: a BEME systematic review. Med
Teach. 2005;27(1):1028.
34. Fanning RM, Gaba DM. The role of debriefing in simulationbased learning. Simulation Healthc. 2007;2(2):115125.
35. Dieckmann P, Molin Friis S, Lippert A, stergaard D. The art
and science of debriefing in simulation: ideal and practice.
Med Teach. 2009;31(7):287294.
36. Stewart LP. Ethical issues in postexperimental and postexperiential debriefing? Simulation Gaming. 1992;23(2):196211.
37. Kriz WCA. Systemic-constructivist approach to the facilitation and debriefing of simulations and games. Simulation
Gaming. 2010;41(5):663680.
38. Smith-Jentsch KA, Zeisig RL, Acton B, McPherson JA. Team
dimensional training: a strategy for guided team selfcorrection. In: Cannon-Bowers JA, Salas E, ed. Making Decisions Under Stress: Implications for Individual and Team Training.
Washington DC: APA; 1998.
39. Schon D. In: Educating the Reflective Practitioner: Toward a New
Design for Teaching and Learning in the Professions. San Francisco:
Jossey-Bass; 1987.
40. Rudolph JW, Foldy E, Taylor ST. Collaborative off-line reflection: a way to develop skill in action science and action
inquiry. In: Reason P, Bradbury H, ed. Handbook of Action
Research. London: Sage; 2001.
41. Paterson M, Wilcox S, Higgs J. Exploring dimensions of
artistry in reflective practice. Reflective Pract. 2006;7(4):455468.
42. Friedman VJ. Action science: creating communities of inquiry
in communities of practice. In: Reason P, Bradbury H, ed.
Handbook of Action Research: Participatory Inquiry and Practice.
London: Sage; 2001.
43. Kaufman DM. Applying educational theory in practice. BMJ.
2003;326:213216.
44. Izard CE, Kagan J, Zajong RB. Emotions, Cognition, & Behavior.
New York: Cambridge University Press; 1984.
45. Russell JA. Core affect and the psychological construction of
emotion. Psychol Rev. 2003;110(1):145172.
46. Lewin K. Group decision and social change. In: Newcomb TN,
Hartley EL, ed. Readings in Social Psychology. New York: Holt,
Rinehart and Winston; 1947.
47. Lewin K. Field Theory in Social Science. New York: Harper Row;
1951.
48. Schein E. Kurt Lewins change theory in the field and in the
classroom: notes toward a model of managed learning. Syst
Pract Action Res. 1996;9(1):2747.
37 (2013) 166174
49. Schein EA. In: Organizational Culture and Leadership, 3rd ed. San
Francisco, CA: Jossey-Bass; 2004.
50. Kneebone R. Simulation and transformational change: the
paradox of expertise. Acad Med. 2009;84:954957.
51. Rudolph JW, Simon R, Dufresne RL, Raemer DB. Theres no
such thing as a non-judgmental debriefing: a theory and
method for debriefing with good judgment. Simulation Healthc.
2006;1:4955.
52. Rudolph JR, Simon R, Raemer DB, Eppich WJ. Debriefing as
formative assessment: closing performance gaps in medical
education. Acad Emerg Med. 2008;15(11):10101016.
53. Senge P. The Fifth Discipline: The Art and Practice of the Learning
Organization. New York: Currency Doubleday; 1990.
54. Argyris C, Schon D. Organizational Learning II: Theory, Method,
and Practice. Reading MA: Addison Wesley; 1996.
55. Edmonson A. Psychological safety and learning behavior in
work teams. Adm Sci Q. 1999;44:350383.
56. Dieckman P, Gaba D, Rall M. Deepening the theoretical
foundations of patient simulation as social practice. Simulation Healthc. 2007;2:183193.
57. Salas E, Klein C, King H, et al. Debriefing medical teams: 12
evidence-based best practices. Jt Comm J Qual Patient Saf.
2008;34(9):518527.
58. Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the operating room with medical team training.
Am J Surg. 2005;190:770774.
59. Papaspyros SC, Javangula KC, Adluri RK, Regan O. Briefing and
debriefing in the operating room. Analysis of impact on
theatre team attitude and patient safety. Interact Cardiovasc
Thorac Surg. 2010;10(1):4347.
60. Corbett N, Hurko P, Vallee JT. Debriefing as a strategic tool for
performance improvement. J Obstet Gynecol Neonatal Nurs.
2012;41:572579.
61. Klair MB. The mediated debrief of problem flights. In: Dismukes RK, Smith GM, ed. Facilitation and Debriefing in Aviation
Training and Operations. Burlington, Vermont: Ashgate; 2000.
62. Mills P, Neily J, RN, Dunn E. Teamwork and communication in
surgical teams: implications for patient safety. J Am Coll Surg.
2008;206:107112.
63. Tannenbaum S, Cerasoli C. Do team and individual debriefs
enhance performance? A meta-analysis. Human Factors.
http://dx.doi.org/10.1177/0018720812448394 [Published online
before print June 4, 2012].
64. Brett-Fleegler M, Rudolph J, Eppich W, et al. Debriefing
assessment for simulation in healthcare: development and
psychometric properties. Simulation Healthc. 2012;7(5):288294.