While last year’s articles explained the pros and cons of medical simulation, they didn’t address the one thing that brings the most value to the whole training experience: the debriefing process. Debriefing usually occurs at the end of a learning activity or computerized simulation and is a way to help students bring closure to the experience. Basically, it’s a question and answer session between students and teachers, and it’s designed to help students thoughtfully reflect about the learning activity they’ve just completed. When done properly, debriefing can provide valuable information to instructors about the usefulness of the EMS training activity, as well as to the first-responder about the level of his or her professional skills.
How Debriefing Works
Debriefing got its start in the military. Pilots and soldiers are debriefed after a mission for the purpose of information gathering, as well as to instruct the individual about what type of information can be released to the public and what information is restricted. Another purpose of the military debriefing is to assess the individual and return him or her to regular duties as soon as possible.
Debriefings are also used by grief counselors and disaster workers as part of an emergency intervention to help people who have recently experienced major loss or suffering. These cases include hurricanes, earthquakes, school shootings, and other situations that involve fear, injury, extreme discomfort, property damage or loss of friends and loved ones. The goal of the debriefing is to reduce the likelihood of post-traumatic stress disorder, or other psychological problems.
In the world of medical simulation, the purpose of a debrief after an exercise is to help the first responder look back on the event and to honestly evaluate his performance, as well as the team’s performance. The ideal outcome would be that he is able to link what happened in the simulated exercise to real-life situations, and that he feels he’s able to discuss his thoughts with the other participants in a safe, non-judgmental environment. When he can ask questions, clear and organize his thoughts, and willingly accept his instructor’s teaching points, that’s when real learning occurs.
You’ve probably heard the phrase, “Don’t put the cart before the horse,” which in essence means don’t skip the proper steps on any project or job if you want to have the proper outcome. That is definitely true for the simulation and gaming process. Before a simulation exercise even begins, there’s one important step that must be taken if students are to reap the full benefits of the activity. That important step is called the pre-brief.
A pre-brief lays the groundwork for the whole simulation experience. During a pre-brief, it’s the facilitator’s responsibility to clearly outline the educational and clinical objectives — basically, to explain to participants exactly what will happen and what they will learn. The pre-brief topics should include:
- A situation summary of the simulation exercise, i.e. there’s been a fire or a car accident with multiple traumas
- An explanation of each person’s role during the exercise and what the expectations are
- An overview of the safety precautions participants should take, i.e. there’s been a gas leak
- A discussion about confidentiality among participants following the exercise
The pre-brief could be compared to a narrator’s job of setting the stage for a story or play. Unfortunately, a facilitator’s failure to perform a pre-briefing will almost certainly lead to an exercise ending that’s not so happily-ever-after. If students are unclear about the exercise, its purpose and their roles, then there are no benchmarks by which to measure their performance at the end of the event. The lack of a pre-brief equates to wasted time and money, not to mention a less-than-stellar learning experience.
The Simulation Experience
Confucius once said, “I hear and I forget. I see and I remember. I do and I understand.” That pretty much sums up the value of the simulation experience. Participants have the opportunity to learn in a fun, interesting, and interactive manner. The situations are controlled, so firefighters, nurses, law enforcement officers and EMS professionals can benefit from real-life simulated cross-training in a safe, non-life threatening environment. That means these first responders aren’t left to learn on the job, when the lives of patients are at stake. Medical simulation helps build their confidence, improves their professional skills, and prepares them for a wide variety of scenarios. The importance of simulation training cannot be overstated.
The Facilitator’s Role in Debriefing
Facilitating is a multi-faceted job, and it comes with a high level of responsibility. In addition to preparing participants before the activity with a pre-brief and overseeing the actual simulation experience, the facilitator must take and keep control of the reflective, or debriefing process. The object is to provide a supportive climate where students feel valued, respected, and free to learn in a dignified environment. Participants need to be able to share their experiences and feelings in an open and honest manner, and to know that the focus of the debrief is on the performance, rather than on the performer. In simple terms, the facilitator must create a debriefing that is a safety zone, rather than a place of confrontation.
The primary purpose of the debriefing is to help the participants understand what happened, to find out what the participants learned, and to compare that information against what the original objective was for the simulation exercise. And while there is no standard length of time for a debrief, it is normally at least twice as long as the actual simulation event.
A good debriefer realizes that the learning does not usually come in the form of teaching; the simulation experience has already done the teaching. Rather, the primary tools of a debriefer are questions, listening, and a journal or recording device to document the discussion. These are the other responsibilities of that person:
- Establish oneself as a co-learner, rather than an expert or an authority
- Keep things on track and focused on the task at hand
- Ask the participants clear and direct questions
- Step in and change the subject if participants become defensive or begin to raise voices and use abrasive language
- Get team members to turn complaints about what went wrong during the simulation exercise into positive actions
- When a participant gets stuck in a complaint mode, pointedly ask them “Okay, what do we do about that?”
Facilitators must truly perform a juggling act, since they need to give participants enough time to talk about their individual experiences, but slowly direct the discussions away from the personal and more towards the group performance. While it’s important for everyone to feel that they’ve had the chance to express their feelings and that they’ve been heard and understood, the overall team dynamic and communication is the overriding factor. First responders rely on one another, so it’s vital that they discuss the team’s goals prior to the simulation exercise and how their work as a group measured up afterwards.
A facilitator has led a successful debriefing when the participants agree upon a clear plan for improvement following their group discussion. They will address the following questions and make group decisions about the outcomes: What did go well? What didn’t go well? Why did things happen the way they happened? What will be different next time? How can we use this information in the future?
At the end of the day, the successful simulation debriefing will accomplish the following:
- Improve communication
- Improve team work skills
- Improve awareness through clarity of roles/responsibilities
- Improve information sharing
- Eliminate barriers to quality and safety
- Increase positive outcomes
- Reduce errors
- Creates a culture of safety
Evaluating the Experience
It only makes sense that an experienced facilitator will be more likely to lead a successful simulation exercise and debriefing than a novice facilitator. In the same way that participants commit to a training activity and expose their professional strengths and weaknesses to themselves and others, so must a facilitator if he or she wishes to build a knowledge base and to grow as an educator.
There are a number of organizations that offer advanced courses in debriefing skills. It’s also recommended that early on in a facilitator’s career, they select an expert role model who is willing to mentor them as they gain experience and become more comfortable with all aspects of the simulation process: pre-briefing, simulation exercises, and debriefing.
Another way facilitators can improve their skills is to ask simulation participants to complete an evaluation at the end of a debrief. Students’ written feedback can provide great insight, offering praise for the facilitator’s strengths, as well as suggestions for areas of improvement. It’s imperative for a facilitator to take stock of his or her skills and to be humble enough to accept constructive criticism when necessary.
From Simulation to the Real World
While debriefing after a training exercise is of vital importance, first responders must understand that it is just as important to debrief after real-life patient care situations. Due to the hurried pace of the first responder environment, we often move from one emergency to the next without really reviewing each care-giving situation and evaluating our performance, both personally and within the group context. If your team wants to improve its behavior and strengthen the feeling of cohesiveness between its members, regular debriefing is key.
DA Kolb, an educational pioneer who specialized in learning through experience, once said that, “Without reflection, one will continue to repeat their mistakes.” As first responders, we’re not in the business of making mistakes. We’re in the business of saving lives. Let’s use debriefing as a way to do that even better.
Amar Patel is the Director of the Center for Innovative Learning at WakeMed Health and Hospitals. Mr. Patel is responsible for integrating technology based educational programs to include human patient simulation, healthcare gaming, and hybrid education into regional educational programs. As a member of the Center for Patient Safety, Mr. Patel strives daily to make changes to processes in healthcare that will directly improve patient and provider safety.