The Art and Science of Debriefing

1. The Art and Science of Debriefing Maria Overstreet, PhD, RN, CCNS

2. Who Am I? • Nashville Native • History: Nurse for 25 years • Simulation: just happened into it… • Debriefing: Chose to perform research • Simulation Consultant: Enjoy doing!

3. Objectives • Learner will become more knowledgeable of: • Debriefing in respect to: • History • Meaning • Concepts • Methods • Application

4. Debriefing • Has anyone ever facilitated a simulation debriefing? • How do you define Debriefing?

5. Debriefing the Debriefers

6. Literature of Debriefing: Military • WWII, Army’s chief historian, Brigadier General Marshall • Performed 1st Historical Group Debriefing (HGD) • Soldiers recounted events of combat, feelings, & decisions • Unexpected finding was psychological benefits • Termed Spiritual Purging symbolizing cleansing of one’s actions during combat • Fillion, Clements, Averill, & Virgil (2002), MacDonald (2003)

7. Literature of Debriefing: Psychology • Mitchell (1983) a psychologist • Worked with emergency services personnel • Developed method of debriefing • Critical incident stress debriefing (CISD) • Recount events, discuss actions/decisions, discuss feelings • Dyregrov (1989) adapted Mitchell’s technique • Emphasized process and flexibility • Particularly time and routine

8. Psychology • Red Cross Debriefing of 1989 San Francisco earthquake • Found small group size allowed for more intimate exploration of worker’s thoughts & feelings (12-15 for 2 hours). • Concurs with Dyregrov 2 factors important: • Time & timing • Length of time of debriefing • Proximity to the event

9. Literature of Debriefing: Education • No works from education literature are evidence based research studies. • Provide important theoretical and conceptual information • Lederman (1984) differentiates educational debriefing from other debriefings due to emphasis on the learning derived from the experience. • Proposed term “postexperience analytic discussion process” (Lederman, 1984, p. 415) • Refined term to “cognitive assimilation of experience”

10. Literature of Debriefing: Education

11. Literature of Debriefing: Education

12. Literature of Debriefing: Education

13. Concepts of Literature Important in Debriefing • Communication • Discussion of events: What happened? • Language use: words & body • Time/Timing • Time is a controversial factor • How long, who speaks for how long, & role of silence • Timing: when to introduce or stimulate a discussion • Emotion • Attention to the affective domain: feelings & emotions • Structure • Pattern of organization, how it flows; anticipation of learner of what is to come

14. Research of Healthcare Debriefing • Points to VALUE of debriefing • Savoldelli, et al (2006) • Verbal & verbal + video improved skill performance • Jefferies & Rizzolo (2006) • Learner identified debriefing as the most important design feature of simulations • Learner’s self-confidence ratings increased with active learning followed by reflective exercises

15. Research of Healthcare Debriefing • Lasater (2007) • Studied simulation & critical thinking • Comments on necessity of assisting students to cope with their emotions following simulation • Addresses the affective domain of learning

16. Research of Healthcare Debriefing • Johnson-Russell (2007) • Presents a loose structure for debriefing • Refers to 4 stages: • Introduction • Personal reaction [psychological component] • Discussion of events [What happened?] • Summary [Synthesis of knowledge, meaning making]

17. Theory of Experiential Learning • Dewey (1938) • Learning by doing • Not every experience results in education or learning • LEARNER must: • Interact with environment • Make meaning of the experience from past, present, or future

18. Theory of Experiential Learning • Debriefing by Dewey’s theory of experiential learning… • Reflective component • Provides opportunity to link knowledge and experience or knowledge, skill, and meaning derived by the learner

19. Theory of Experiential Learning • Kolb (1984) • Experiential learning model • Represents 4 cyclic stages learners venture through to understand experiences • Reflective Observation • Discuss experience, ponders what went well & not, seeks affirmation or learns alternative method, gains insight

20. Kolb’s Experiential Learning Model

21. Theory of Experiential Learning • Schön (1987) • Learning through reflecting as it relates to practice professions • Isolated reflection & expanded on its meaning • 2 methods of reflection in practice: • Reflection in action (thinking while performing) • Reflection on action (pose ? To self to change)

22. Research of Nursing Clinical Simulation Debriefing • Overstreet (2009) • Qualitative study • Case study design (4 independent cases) • Data • Observation & field notes • Video of debriefings • Facilitator interview • Facilitator questionnaire • Student questionnaire

23. Overstreet’s Research Findings • Original 4 concepts from literature emerged • Communication • Time/Timing • Structure • Emotion

24. Additional Patterns Emerged • Triangulation of data sources: from both students and facilitators • Accentuate the positive • Higher Order Thinking • Experience Counts

25. Methodology & Design • Qualitative Research • Explore phenomenon through identifying idiosyncratic patterns of behaviors • When little is known • Madjar & Walton, 2001 • Case Study • Investigate a contemporary phenomenon within its real-life context • Multiple sources of data • Yin, 2003

26. Focal Points • Teacher • Student • interaction • Process • time spent in certain aspects of exchange • Content • what is communicated

27. Actual Research • IRB Approval • Protocol remained same for each data collection • Observe • Videotape • Student Questionnaire • Educator Semi-structured Interview • Educator Questionnaire • Field Notes

28. Case Study Analysis of Data • Triangulation of multiple data sources • Categorical aggregation • Time-ordered analysis • Pattern matching • Cross-case synthesis

29. Case 1: Using Storytelling • Pre-simulation – 30 • Simulation – 30 • Debriefing – 25 • Content – Med/surg • Students – 6 (22 yr old) • AD, (1 AA, 5 Cau, 1♂) • Educator – Cau, ♀ • 23 yr RN, used personal storytelling for emphasis • Tone - Natural

30. Case 2: The Therapeutic Milieu • Pre-simulation – 5 • Simulation – 105 • Debriefing – 47 • Content – Skill practice • Communication w/pt. • Students – 7 (22 yr old) • BSN, (1AA, 6 Cau, all ♀) • Educator – 2, Cau, ♀ • 14 & 4 yrs RN • Structured, safe & trusting atmosphere

31. Case 3: The Critical, Critical Care Nurse • Pre-simulation – 5 • Simulation – 50 • Debriefing – 28 • Content – Cardiac/ED • Decisions at point of care • Students – 3 (38 yr old) • BSN, (All Cau, 1 ♂, previous roles) • Educator – 2, Cau, ♀ • 18/10 yr RN • Feedback(-),(93 ?/20min)

32. Case 4: Preparing for The Future • Pre-simulation – 5 • Simulation – 90 • Debriefing – 38 • Content-Sepsis/ED/ICU • Decisions at point of care • Student – 7 (22 yr old) • BSN, 1 AA, 1 ♂ • Educator - ♀ Cau. • 38 yr RN/34 yr teaching • Interweave of emotion

33. Across Cases

34. Educator Demographics and Questionnaire Answers

35. Patterns • Structure • All 4 heavy in structure, physical environment • Case 1: driven by written questions • Case 2: (+) peer feedback • Case 3: knowledge questions • Case 4: less defined: variety of teaching methods • Communication • Listening: to hear with thoughtful attention • Language: words, pronunciation, includes tone and body • Pattern frequencies: links, swoops, timing • Case 4 – swoop 8 times / Case 2 – no swoops in analysis

36. Patterns • Time • Time spent in debriefing – 25-47 min. • Educator talk time 18 – 30 min. • Silence 0 – 5 min. • Case 2: Outlier student talk time • Case 3: Students answered 57 X in 2.5 min(2.6 sec/answer) • Emotion • Case 1 & 4: Storytelling and interweave of emotion • Case 3: Negative vs positive feedback (18/9/5) • “I was thinking their knowledge base was a little more than what it may have been”

37. New Patterns Emerged • Accentuate the Positive • Higher Order Thinking • Experience Counts

38. Accentuate the Positive • Educators unanimously perceived students & themselves (+) • “I try to end it in a positive by asking the students a couple of things they learned today that they didn’t know before…” • “Cause we want them to leave feeling positive about simulation and not being terrified and being embarrassed cause we are using simulation in every single course” • Students: What did today’s debriefing mean? • “It was feedback I needed to hear. It helps me identify + and -.” • “to discuss people’s strengths and areas that need to be worked on in a positive manner”

39. Higher Order Thinking • Putting It All Together • Meaning making: Students • “Debriefing just put all the pieces of the puzzle together” • “Debriefing helped to pull everything together & make sense of it all” • Meaning making: Educators • Case 1: predetermined goal to connect theory & practice • Case 2: tie together student improvement • Case 3: tried to tie together knowledge from simulation • Case 4: cannot refrain from teachable moment

40. Higher Order Thinking • Decision Making and Critical Thinking • Case 1 & 3: Dialogue about how decisions were made • Case 3: “You get to find out more about what they were thinking…” • Case 2: Skill focused: therapeutic communication process • Case 4: minimal skill focus, knowledge questions to ponder, overlaid with attention to attitude • Students: “Helps you learn & think critically” “to focus on your patient & not the monitors. Also it is important to think critically & prioritize your care”

41. Experience Counts • Educators brought themselves to debriefing • More experienced vs. less experienced • Students value experience • “We practiced on a plastic dummy which just increased our chances of responding appropriately to the situation in real life”

42. Strengths & Limitations of Study

43. So What? • Theory • Dewey, Kolb, Schön • Literature • Military, Psychology, Education • Concepts • Communication, Time/Timing, Structure, Emotion • Research Patterns • Accentuate +, higher order thinking, experience counts

44. Gathered More Knowledge • Information to consider as you develop your own style of debriefing • Ask yourself the question • How will I address these concepts in debriefing?

45. Consider Objectives • Objectives for simulation add depth to debriefing • Are you going to allow the objectives for the simulation to guide the debriefing, structure the debriefing, limit the debriefing…

46. How do objectives for simulation guide debriefing? • View code simulation • What is the objective for the simulation? • 1.) to feel the urgency of being involved in a code situation? • 2.) to administer accurate CPR?

47. How much time? • Will you be very rigid with time • Will you be lax with time • Literature points to time as important: • How long? … As long as the experiential learning • For true reflection – have to spend silent time thinking

48. How do I communicate? • Video tape yourself…you will learn a lot! • Language is a powerful tool. • Example: [ + / Δ ] • How do you communicate this to the learner? • What was good/bad? • What was done well/what can be improved? • How do you list these items? • Include the learner in coming up with the items

49. Communicate Your Findings • Theory • Your theory • Literature • What literature you produce • Concepts • Concepts you discover in your practice or observe in other’s practice • Research Patterns • Patterns you produce or you observe