Abstract
KEYWORDS
Standard
All simulation-based educational (SBE) activities must include a planned debriefing process. This debriefing process may include any of the activities of feedback, debriefing, and/or guided reflection. This facilitated process is accomplished using multiple techniques and must be based on theoretical frameworks and/or evidence-based concepts. The debriefing process needs to be adaptable to all simulation-based modalities. In this standard, the term ``process" refers to feedback, debriefing, and/or guided reflection except when indicated.
The process aims to identify and resolve gaps in knowledge, skills, attitudes, and communication related to the individual, team, and/or system. The goal of the debriefing process is to assist in the development of insights, improve future performance, and promote the transfer and integration of learning to practice. Although the planned session for implementing the debriefing process should not be an additional lecture opportunity, much learning occurs during this time.
Background
Learning is dependent on the integration of experience and conscious consideration or reflection of the activity. Conscious reflection, the self-monitoring or insightfulness that occurs within or after an SBE, allows learners the opportunity to identify knowledge gaps and understand contradictions between one's vision or actions and actual practice
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. Conscious reflection assists an individual in developing insights by connecting thoughts, beliefs, and action2.
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, 6.
, 7.
, 8.
, 9.
. The debriefing process of an SBE activity can be integrated at designated points (debriefing-on-demand) and/or as a post-scenario activity.The debriefing process includes three different strategies or techniques (feedback, debriefing, and/or guided reflection). It is important to note that no particular strategy or technique is necessarily preferential and more than one may be implemented. The type or combination of techniques (blended approach) selected depends on the level or type of learner, desired learning, and/or evaluation outcomes of the simulation-based experience
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.- •Feedback is a unidirectional process where “information [is] transferred between learner, facilitator, simulator, or peer(s) with the intention of improving the understanding of concepts or aspects of performance.” (p. 18)1.. Feedback can be delivered by a facilitator, a technological device, a computer, a standardized patient (or a simulated person), or by other learners as long as it is part of the learning process1.,13.,14..
- •Debriefing is a bidirectional, “formal, collaborative, reflective process within the simulation learning activity” (p. 14)1.. The debriefing encourages learners’ reflective thinking and can be integrated at designated points within an SBE activity or as a post-scenario activity. A debriefing session can be divided into several phases. During the description phase, learners are reminded of the objectives of the simulation and purpose of the debriefing. The reaction/defuse phase allows learners to explore their reactions to the experience. During the analysis/discovery phase, the facilitator assists the learners’ exploration into the experiences, facilitates understanding of material, and helps identify knowledge gaps. The summary/application phase provides an opportunity to recap the experience, identify insights, and allows exploration of how the knowledge, skills, and attitudes of the experience could be transferred to the actual patient care environment15.,16..
- •Guided reflection is a process by which facilitators encourage learners to explore the critical elements of an experience in an effort to gain understanding and insight. Guided reflection, an intellectual and affective activity, promotes the linkage of theory with practice and research (p. 20). Guided reflection can be integrated into a debriefing or be accomplished through an exercise following the SBE event such as journaling and open discussions (p. 20)1..
Clinical reasoning and reflective thinking are promoted by the appropriate integration of feedback, debriefing, and/or guided reflection
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, 18.
. The debriefing process promotes understanding, enhances learning, increases competence in clinical performance, and supports transfer of knowledge, skills, and attitudes19.
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, 21.
while fostering self-confidence, -awareness, and -efficacy22.
,23.
. The focus of this process is the acknowledgement and integration of best practices to promote safe, quality patient care, and foster the development of the learner's professional and clinical role.7.
,24.
. Therefore, the benefit of this process depends on the skills of the facilitator and/or the design of an automated system19.
,25.
. The guidance and critique provided during the debriefing process by the facilitator or other system (e.g., artificial intelligence) ensures the best possible learning outcomes10.
,26.
, 27.
, 28.
.The ultimate goal of the debriefing process is to promote reflective thinking. Reflection, the conscious consideration of the meaning and implication of an action, includes the assimilation of knowledge, skills, and attitudes with pre-existing knowledge
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,4.
,29.
. Reflection can lead to new interpretations by the learners; this cognitive reframing or looking at a situation from a different perspective is essential to learning and the development and maintenance of professional competencies3.
,29.
.Facilitator(s) are challenged to maintain a safe learning or evaluation environment during the debriefing process
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. This safe environment must be maintained while they observe the behavior of the learner(s), encourage open discussion, provide appropriate feedback, facilitate reflective thinking, and generate solutions to unanticipated situations. The acquisition and progression in the expertise of these skills is a continuous process that demands constant attention, practice, and development. This can be achieved in multiple ways including attending courses, mentoring, certification and/or credentialing, peer feedback, and/or self-analysis30.
,31.
.Potential outcomes of following this standard include the learners’ ability to attain changes in learning outcomes or behavior(s) transfer of learning to practice
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,25.
,32.
.Criteria Necessary to Meet this Standard
The debriefing process is:
- 1Planned and incorporated into the simulation-based experience in an appropriate manner in order to guide the learner(s) in achieving the desired learning or evaluation outcomes.
- 2Constructed, designed and/or facilitated by a person(s) or system capable and/or competent in providing appropriate feedback, debriefing, and/or guided reflection.
- 3Conducted in a manner that promotes self, team, and/or systems analysis. This process should encourage reflection, exploration of knowledge, and identification of performance/system deficits while maintaining psychological safety and confidentiality.
- 4Planned and structured in a purposeful way based on theoretical frameworks and/or evidenced-based concepts.
Criterion 1: The debriefing process is planned and incorporated into the simulation-based experience in an appropriate manner in order to guide the learner(s) in achieving the desired learning outcomes.
Required Elements:
- •The debriefing process should:
- ○Be preceded with a prebriefing/briefing and an SBE (Follow the Healthcare Simulation Standards of Best PracticeTM (HSSOBPTM) Prebriefing: Preparation and Briefing)16.,33..
- ○Be integrated within or conducted after an SBE activity (Follow the HSSOBPTM Simulation Design)15.,16.,33..
- ○Be learner-centered and structured according to the educational and experience level of the learner(s) and/or team16.,20..
- ○Be individualized, specific, based on observable behavior, evidenced- based, and timely11.,20.,34..
- ○Ensure resources are available to support content, provide clarification, and assist with critical reflection22.,35..
- ○Be adaptable allowing for modifications in the approach and the reframing15.,36..
- ○Occur in multiple phases to allow deeper exploration of the learners’ performance and thinking process15.,33.,35..
- ○
Criterion 2: The debriefing process is constructed, designed and/or facilitated by a person(s) or technology-enhanced system capable and/or competent in providing appropriate feedback, debriefing, and/or guided reflection.
Required Elements:
- •The facilitator, facilitators (when codebriefing is conducted) and/or developer of the technology-enhanced system should:
- ○Be skilled in evidence-based practices related to the debriefing process.
- ○Be knowledgeable and familiar with the case or procedure and its objectives as well as the expected or desired performance of the learner(s)15.,25..
- ○Demonstrate proficiency and strive for continued competence through professional development in the process of providing feedback, debriefing, and/or guided reflection10.,32..
- ○Be recognized by the learner(s) as a credible source15.,37..
- ○Allow adequate time to assist the learner(s) in achieving the activity's desired outcomes, address critical elements, and discuss identified performance or systems gaps15.,25.,38.. The amount of time allocated to the debriefing process is multifactorial, including, but not limited to variables such as the objectives of the SBE, and the performance of the learner(s). The time allocation does not have a set relationship to the preceding activity.
- ○Consider group size that supports the debriefing process and allows engagement with each learner39.. Group size may vary depending upon the setting. All learners may actively participate in the scenario, while others may observe and still participate in the debrief. Learners may be in-person, remote via local classroom video, or participating in a virtual learning experience using a web-based conferencing platform, etc.
- ○Use Socratic approach, inquiry, open-ended and/or reflective questions, and advocacy to guide the conversation within the group to promote review, self-awareness, and critical and reflective thinking20.,25.,40..
- ○Incorporate communication skills such as active listening, a non-judgmental demeanor, and silence to encourage learner(s) input, self-analysis, and reflection21.,25.,39..
- ○Provide an unbiased critique of performance with the intent to correct errors, promote understanding, facilitate comprehension, and promote insightfulness20.,35..
- ○Provide both positive and constructive analysis that consolidates the teaching message and/or reinforces positive behavior15..
- ○Identify performance gaps or process issues based on the expected outcomes of the simulation-based experience37.,38..
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Criterion 3: The debriefing process is conducted in a manner that promotes self, team, and/or systems analysis. This process should encourage reflection, exploration of knowledge, and resolution of performance/system gaps while maintaining psychological safety and confidentiality.
Required Elements:
- •The process should:
- ○Be conducted in an environment with adequate facilities to allow for privacy, open discussion, trust, review, and confidentiality20.,25..
- ○Incorporate multiple points of view, such as self, peer, small/large group, external observers, standardized patients, operations/technology specialists, or automated performance analysis and feedback systems34.,35..
- ○Be conducted in an environment with appropriate access to support learners in the case of an unexpected distress or outcome(s)7.,41..
- ○Be focused on learner(s’) behavior and related to the objectives of the activity13.,20..
- ○Guide the learner(s) toward comprehension and understanding to achieve the desired objectives and outcomes19.,26.,33..
- ○Allow the observation and discussion of the learner's response and/or behavior to improve performance particularly when the learner is unaware of a deficit. The discussion must also allow for clarification of the frames or context that may not be known by the observer41.,42..
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Criterion 4: The debriefing process is planned and structured in a purposeful way based on theoretical frameworks and/or evidenced-based concepts.
Required Elements:
- •The debriefing process should:
- ○Be selected depending on the complexity of the scenario, contexts, learner(s), time available, and the learning objectives10..
- ○Be structured and incorporate various phases11.,15.,21.,25.,38..
- ○Facilitate analysis or critique of the team, system, or the learner themself11.,30.,38..
- ○Allow for flexibility based on different learners, identified objectives and outcomes, timeframe, and the simulation setting10..
- ○Be designed to promote critical thinking and reflection25.,30.,39..
- ○Be designed to encourage learners to search for evidence-based solutions5.,25.,39..
- ○Foster the learner(s’) ability to apply/transfer the knowledge, skills and attitudes obtained during SBE to actual clinical settings16.,43..
- ○Acknowledge that each learner's perspective is valid and may not be fully understood without exploration41.,42.,44..
- ○
Resources
Even if a debriefing model does not formally integrate the Socratic approach, the facilitator should incorporate the strategy of asking essential questions
40.
.- •Current models/structures for debriefing include but are not limited to the following:
- •Debriefing for Meaningful Learning (DML)45.
- •Debriefing with Good Judgment4.,46.
- •Diamond47.
- •Gather, Analyze, Summarize (GAS)48.
- •PEARLS for System Integration (PSI) Frameworks49.,50.
- •Promoting Excellence and Reflective Learning in Simulation (PEARLS)50.
- •Plus-Delta24.,51.
- •Review the event, Encourage team participation, Focused feedback, Listen to each other, Emphasize key points, Communicate clearly, and Transform the future (REFLECT)52.
- •The 3D Model of Debriefing (Defusing, Discovering, and Deepening)53.
- •The Critical Incident Stress Debriefing Model51.
- •
- •Current frameworks to assist in providing feedback (this list is not exhaustive) are:
- •Debriefing Assessment for Simulation in Healthcare (DASH)57.,58.(https://harvardmedsim.org/debriefing-assessment-for-simulation-in-healthcare-dash/)
Center for Medical Simulation. Debriefing Assessment for Simulation in Healthcare (DASH). Retrieved from https://harvardmedsim.org/debriefing-assessment-for-simulation-in-healthcare-dash/
- •Debriefing for Meaningful Learning Evaluation Scale59.
- •Feedback Assessment for Clinical Education (FACE)60.(https://harvardmedsim.org/feedback-assessment-clinical-education.php)
- •Objective Structured Assessment of Debriefing (OSAD)61.
- Zamjahn J.B.
- Baroni de Carvalho R.
- Bronson M.H.
- Garbee D.D.
- Paige J.T.
eAssessment: development of an electronic version of the Objective Structured Assessment of Debriefing tool to streamline evaluation of video recorded debriefings.Journal of the American Medical Informatics Association. 2018; 25: 1284-1291 - •Peer Assessment Debriefing Instrument (PADI)62.
- •Simulation Effectiveness Tool – Modified (SET-M)63.(https://caehealthcare.com/media/files/Simulation-Effectiveness-Tool.pdf)
Original INACSL Standard
The INASCL Board of Directors. (2011). Standard VI: The debriefing process. Clinical Simulation in Nursing, 7(4S), s16-s17. http: //dx.doi.org/10.1016/j.ecns.2011.05.010.
Subsequent Standard
Subsequent INACSL Standards Decker, S., Fey, M., Sideras, S., Caballero, S., Boese, T., Franklin, A. E., ., & Meakim, C. (2013). Standards of best practice: Simulation standard VI: The debriefing process. Clinical Simulation in Nursing, 9(6), S26-S29.
INACSL Standards Committee (2016, December). INACSL standards of best practice: SimulationSM Debriefing. Clinical Simulation in Nursing, 12(S), S21-S25. http://dx.doi.org/10.1016/j.ecns.2016.09.008
About the International Nursing Association for Clinical Simulation and Learning (INACSL)
The International Nursing Association for Clinical Simulation and Learning (INACSL) is the global leader in transforming practice to improve patient safety through excellence in health care simulation. INACSL is a community of practice for simulation where members can network with simulation leaders, educators, researchers, and industry partners. INACSL also provided the original living documents INACSL Standards of Best Practice: SimulationSM, an evidence-based framework to guide simulation design, implementation, debriefing, evaluation, and research. The Healthcare Simulation Standards of Best PracticeTM are provided with the support and input of the international community and sponsored by INACSL.
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© 2021 Published by Elsevier Inc. on behalf of International Nursing Association for Clinical Simulation and Learning.
