Simulation Learning

Debriefing is defined as a “discussion between two or more individuals in which aspects of a performance are explored and analyzed with the aim of gaining insight that impacts the quality of future clinical practice” (Cheng et al., 2015 p. 69).

In healthcare simulation, debriefing occurs after a simulated activity and is described as “a venue for learners to reflect on actions, discuss areas for improvement, and incorporate new information with previous knowledge” (Cheng et al., 2016, p 32). The goal of debriefing is to help transform experience into reflection and learning. Kolb’s Experiential Learning Cycle (described on the Theories page) outlines this process.

The debriefing process aims to identify and address any gaps noted in knowledge, skills, or communication. During the simulation, facilitators compare the desired outcomes with the performance they observe in the simulation. The difference between the observed and desired outcomes is known as the performance gap (Simon, Raemer, & Rudolph, 2010; Watt et al., 2021). Debriefing time should not be used for planned didactic lectures, but directive feedback/teaching may be necessary to address performance or knowledge gaps.

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The Healthcare Simulation Standards of Best Practice (HSSOBP™) describe the importance of debriefing. Literature highlights the crucial role debriefing plays in SBE. The most critical component to a successful and impactful simulation-based learning experience is the debriefing after the event (Cheng et el., 2015; Cheng et al., 2016; Decker et al., 2021; Eppich & Cheng 2015; Ross, 2020; Watt et al., 2021). A deliberate debriefing process must be used (Cheng, Eppich, Kolbe, Meguerdichian, Bajaj & Grant, 2020). Simulation without debriefing can be detrimental for participants.

According to the 2021 HSSOBP™ Debriefing Process Standard, the debriefing process is:

1. Planned and incorporated into the simulation-based experience in an appropriate manner to guide learners in achieving the desired learning or evaluation outcomes.
2. Constructed, designed and/or facilitated by a person(s) or system competent in providing appropriate feedback, debriefing, and/or guided reflection.
3. Conducted 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.
4. Planned and structured in a purposeful way based on theoretical frameworks and/or evidence-based concepts.

(Decker, et al..2021)

©2021 INACSL. Used with permission.

Debriefing assists learners with transforming experiences into learning through reflection. It should include:

• Active participation of learners
• Developmental intent focused on learning and improving performance
• Discussion of specific events
• Input from multiple sources

The goal of debriefing is to promote clinical reasoning and reflective thinking. One important reason to debrief is to understand the participant’s rationale, point of view, or frame. Think, 'What’s their frame (WTF)?'. It is difficult to discern critical thinking or rationale merely from observing behaviors (Eppich & Cheng, 2015).

Additional reasons for debriefing include:

• Novice learners may not accurately measure their actual clinical performance when they are learning both their roles and new skills. They require practice not only in skills, but in reflection on their abilities (Ng & Lugassy, 2020)
• It is common for novice learners to revert to procedural skills rather than look for relevant information to critically analyze the situation (Benner, Tanner, & Chesla, 2009; Ng & Lugassy, 2020).
• Novice practitioners often make decisions based on doing rather than reflecting or thinking about the situation.
• Debriefing helps to accurately determine if learning outcomes are met.
• Debriefing helps to improve poor performance and reinforce good performance.
• Participant engagement during the debrief yields better retention, understanding and deeper knowledge.

Debriefing can occur in many settings and formats.

Debriefing may be guided by a facilitator (facilitator-guided) or the participant (self-guided) (Sawyer, Eppich, Brett-Fleegler, Grant & Cheng, 2016). Self-guided debriefs are more common after virtual simulation. Facilitator-guided debriefs are more common in standard healthcare simulation. This guide focuses on facilitator-guided debriefing.

Post-event debriefing is an intentional discussion between the facilitator(s) and participants following an experience. It allows participants to gain a clear understanding of their actions and thought processes to promote learning outcomes and enhance future clinical performance.

There are multiple forms of post-event debriefing:

• Clinical debriefing occurs by the team after a situation in clinical practice.
• Psychological team debriefings are intended to reduce psychological harm after an experienced trauma (e.g., critical incident stress debriefing).
• Learning-oriented debriefing refers to debriefing after a simulation-based education activity, focused on learning objectives. This guide focuses on learning-oriented debriefing, and refers to post-event debriefing as simply debriefing, or the debrief.

Debriefing can occur immediately following a simulation, or it can be planned for a future time. Best practice is to have the debrief as close in time to the simulated experience as possible.

Debriefing often occurs in person, where groups are physically present together. However, the increase in virtual simulation and computer-based simulation has increased the need for virtual debriefing.

Read more about virtual debriefing in this article:

Debriefing can occur with one or more facilitators. Using more than one facilitator is referred to as co-facilitating or co-debriefing. Preplanned strategies are needed to promote an effective debrief. Interprofessional considerations must be addressed when the participants and the debriefers are from different professions. Consider the variable scope, team functioning, communication, and understanding of roles among the group.

Read more about co-debriefing strategies in this article:

Debriefers may use recorded videos of the simulated experience to guide the debrief. This is referred to as video-assisted debriefing. There are positive and negative aspects associated with video-assisted debriefs. Ensure strategies to promote psychological safety are used, including the purpose for using video recording and confidentiality.

To learn more about the topic, consider reading:

There are several phases in the debriefing process. Most evidence-informed frameworks will include some variation of these phases, but they may use slightly different terminology.

• Reaction/defuse – Allows participants to ‘vent’ and release initial emotions from the simulation. For example, letting a participant briefly discuss frustration related to equipment can allow them to engage in the learning process.
• Description – Learning objectives are reiterated, and a shared understanding of the case develops.
• Analysis/discovery – Uses concrete examples to explore participants experiences to identify knowledge or performance gaps and celebrate successes.
• Summary/application - Summarizes the simulation experience. Participants reflect on how the knowledge, skills and attitudes gained can be applied to the patient care environment.

Psychological safety is necessary for effective debriefings. Given the nature of simulation-based education, inherent threats to psychological safety are present (Kolbe et al., 2020). Restoring and re-establishing a safe learning environment during the debriefing phase is crucial for effective learning. Kolbe et al (2020, p.164) describe a psychologically safe debriefing environment as giving the “the perception that it is safe to take interpersonal risks and that one will not be embarrassed, rejected or otherwise punished for speaking their mind, not knowing or asking questions”.

Psychological safety is needed on three levels:

1. The individual level
2. The team level
3. The organization level

Kolbe et al. (2020) state that psychological safety during an interprofessional debriefing can be unstable as not all members of the team may experience the same level of psychological safety at the same time.

The strategies used in the prebrief phase to promote psychological safety will set the stage for psychological safety in the debrief. That alone will not ensure it. Similar strategies must be incorporated into the debrief.

Specific explicit and implicit strategies for establishing, maintaining, and restoring psychological safety during debriefing include:

• Explicitly reiterate the actions taken to establish psychological safety and maintain confidentiality.
• Explain the debriefing process including the role of facilitators, participants, and observers.
• Normalize poor performance and validate emotions.
• Explicitly invite participants to actively participate and self-reflect and show appreciation when they do so.
• Reiterate The Basic Assumption™ to convey a commitment to respecting participants, acknowledging their curiosity, and understanding their perspectives.
• Use active listening; validate and paraphrase when needed.
• Demonstrate vulnerability.

Read the following article that further describes strategies for psychological safety during debriefing:

The competency of team members conducting a debrief significantly influences learning outcomes (Jeffries, et al., 2016). The debriefing process is complex. The debriefer must have training/education to best facilitate structured post-simulation discussions. Performing the role of a debriefer is an advanced skill but not one that necessarily comes with seniority. Debriefing skills, like all educator facilitation skills, develop over time with practice and feedback. Ongoing professional development, as well as peer feedback, is recommended. Facilitators that assume this role must be both knowledgeable and skilled in understanding the participants’ needs. Facilitators must be flexible in how they conduct a debrief depending on how the simulation unfolds (Ross, 2020).

The role of the debriefer is to:

• Guide the review of objectives and patient care in the SBE.
• Allow learners to vent emotions post-simulation experience.
• Use open-ended questions, silence and pauses to elicit feedback from learners and encourage active participation.
• Use strategies to help the learner reflect on their performance.
• Identify and close performance gaps or correct misconceptions.
• Acknowledge emotions while maintaining the safe container for learning.
• Relate the simulation experience to real-life situations.

(Jeffries et al., 2016)

Other important considerations for the debriefer include:

• The educational impact of the debrief is dependent on the facilitator’s skill set.
• Feedback helps to improve the facilitator's debriefing skills.
• The debriefer must observe the simulation (ideally watching the session in its entirety without performing other roles, such as managing the equipment).
• It is crucial to establish a safe learning environment.
• Sessions should be learner-centred rather than facilitator-centred. Create a learning environment where questions are generated through participant inquiry rather than the debriefer providing lecture-based education).
• Communication is the backbone of debriefing (both verbal and non-verbal).
• Maintain an engaging environment.
• Give equal attention to different experiences or perspectives (avoid taking sides).
• Use expertise wisely and at appropriate times to best facilitate discussions (do not act as ‘superior’).
• Silence can be used as a means of further reflection for the participants and allows time for participants to formulate thoughts and grasp content.
• Do not be afraid to offer critique when warranted in fear of comprising relationships. Withholding critique can lead to missed learning opportunities for all involved.
• Influence a positive culture surrounding SBE and debriefing.

(Kamal et al., 2020; Ross, 2020; Seelandt, Walker, & Kolbe, 2021)

You can use a variety of strategies to debrief simulations, but you must use an evidence-informed, validated framework

Choose a tool that meets your specific needs and become familiar with it.

Commonly used tools/frameworks include:

• Debriefing with Good Judgement (uses an advocacy-inquiry approach)
• Promoting Excellence and Reflective Learning in Simulation (PEARLS) Highlighted below.
• The Debriefing Diamond
• Gather-Analyze-Summarize (GAS)
• 3D Model of Debriefing: Defusing, Discovering and Deepening
• TeamGAINS

(Decker et al., 2021; Rudolph et al., 2006; Eppich & Cheng, 2015; Bajaj et al., 2018)

Integrating principles of equity, diversity and inclusion (EDI) into prebriefing and debriefing sessions prepares learners to provide high-quality, equitable healthcare to patients of diverse backgrounds, with the goal of reducing health disparities. Debriefing allows for the application of EDI concepts presented during the simulation scenario. It promotes discussion of EDI topics in a safe space, and reflection on any biases identified during the simulation experience.

EDI principles can be integrated into simulation debriefings by exploring:

• how certain assumptions might have influenced the learners’ actions or decisions
• how those biases might affect patient care
• how to identify strategies to mitigate them

(Alrimawi et al., 2024).

Novice and experienced debriefers often struggle with how to intervene in difficult situations without compromising the benefits of SBE, and specifically, the debrief. This may include situations when learners are quiet, disengaged, dominant, or display emotional reactions.

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