Summary

In this video, Marc Lazarovici and Christian Boeriu discuss different methods and considerations for effectively facilitating debriefings after a simulation scenario.

The debriefing is universally recognized as the most critical component in simulation, as it is where profound learning occurs and, at the same time, the most challenging aspect of simulation-based education.

There are many reasons why leading effectively a debriefing is difficult:
facilitating group discussions and self-reflection is inherently challenging
managing group dynamics is complex: disengaged learners, dominating participants, or defensive reactions to critiques can hinder the outcome of the debriefing
debriefings need to strike the right balance between creating a psychologically safe environment for self-critique while still addressing performance gaps.

Some structured approaches can assist the facilitator in delivering the debriefing, but nevertheless, a distinct skillset and a “facilitative mindset” quite different from didactic teaching is required.

In the video we talk about three different structured approaches:

• Plus-Delta
• PEARLS
• Diamond Model

Plus-Delta

Plus-Delta [4] is quite a simple method and focuses on self-assessment. It can be used to help the participants to reflect on the whole event or a part of it and to think about their performance. The participants are asked to identify:

• Plus: What went well during the scenario
• Delta: What they would do differently next time

Compared to other methods it is less structured, it is more a strategy that helps the learners to analyze their own performance through these two lenses.
Its straightforward nature makes it also useful for debriefing skills-based scenarios.

PEARLS

PEARLS [5] stands for “Promoting Excellence and Reflective Learning in Simulation”.
This approach allows self-assessment by the learners and guides the facilitator in moderating the session to promote critical reflection. Despite it is not meant to be used to provide teaching, it also allows for the flexibility that is sometimes needed to give a direct feedback or to engage focus teaching.
It provides a comprehensive framework with different approaches for each phase:

• Reaction phase: Learners share initial emotional reactions
• Description phase: Reconstruct a shared mental model of what happened
• Analytic phase: The core self-reflection and analysis using different techniques selected by the facilitator based on needs:
  • Self-guided analysis prompts like Plus-Delta
  • Focused facilitation with approaches like “advocacy-inquiry”
  • Direct instructive feedback if necessary
• Summary phase: Consolidate key lessons and take-aways

PEARLS allows flexibility to use various techniques while providing an overall structure to the debriefing.

Diamond Model

Diamond Model [6] is based on the technique of description, analysis and application along with aspects of the advocacy-inquiry approach and of debriefing with good judgment [7].
It is an approach that helps the facilitator to structure the discussion, also visually, and to avoid the danger of the debriefing being dominated by the discussion on technical skills.
This model aims to structure the debriefing discussion flow into three distinct phases:

• Description: Participants describe their perspective of key events
• Analysis: The facilitator guides an in-depth exploration of thought processes behind actions/decisions using techniques like “advocacy-inquiry”
• Application: Consolidating how lessons can be applied to future practice

The Diamond model provides specific phrasing examples for facilitators to use during each phase. Its phased approach helps maintain a productive analytical discussion flow.

There are many more methods that help the facilitator during the debriefing [8], indicating a different number of phases. Regardless of what you use, the recommendation is to use one structure and stick to it.

Nevertheless the structured approach used, some difficult situations can arise in debriefing. Disengaged learners, conversation dominators, upset participants, defensive learners, aggressive participants can happen and be quite challenging to manage. The debriefer can adopt some proactive approaches to avoid to incur in challenging situations, and reactive approaches, to mitigate these when they happen; the paper [9] provides an insight on the techniques to adopt and we invite you to read the article.

Wrap up

These are the key points to remember for a succesful debriefing [10]:

1. Create a good learning atmosphere and psychological safety. Establishing an environment where learners feel comfortable being open, self-critical, and engaging in candid discussions is paramount. This involves setting clear expectations, ground rules, and a supportive tone.
2. Create and keep up a learning context. This is afterall why we are doing simulation.
3. Provide a clear structure and stick to it. Using a structured approach like PEARL, Plus-Delta, Diamond, etc. rather than an unstructured conversation is recommended. Having and adhering to a defined debriefing structure helps facilitate productive discussions.
4. Support and encourage interesting conversations. While using a structure, facilitators should allow interesting discussions to unfold organically through self-reflection. Asking open-ended questions and allowing silences for deeper thinking promotes insights.
5. Identify and properly address performance gaps. When learners make errors or demonstrate performance gaps, use techniques like “advocacy-inquiry” to explore their reasoning in a non-judgmental way before providing critiques.
6. Highlight and reinforce good performance. In addition to addressing gaps, facilitators should make a point to identify exemplary actions and have learners analyze what made those performances effective.

References

1 Rana SC, Francis U, Zavi L, Ella S, Honein-Abou Haidar G, Peter D. Cultural differences in simulation debriefing: A qualitative analysis. Heliyon. 2023 Mar 25;9(4):e14904. doi: 10.1016/j.heliyon.2023.e14904. PMID: 37064463; PMCID: PMC10102195.

2 Ulmer FF, Sharara-Chami R, Lakissian Z, Stocker M, Scott E, Dieckmann P. Cultural Prototypes and Differences in Simulation Debriefing. Simul Healthc. 2018 Aug;13(4):239-246. doi: 10.1097/SIH.0000000000000320. PMID: 29672469.

3 Geert Hofstede, Culture’s Consequences: Comparing Values, Behaviors, Institutions, and Organizations Across Nations, Sage 2001

4 Cheng, A., Eppich, W., Epps, C. et al. Embracing informed learner self-assessment during debriefing: the art of plus-delta. Adv Simul 6, 22 (2021). https://doi.org/10.1186/s41077-021-00173-1

5 Eppich W, Cheng A. Promoting Excellence and Reflective Learning in Simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simul Healthc. 2015 Apr;10(2):106-15. doi: 10.1097/SIH.0000000000000072. PMID: 25710312.

6 Jaye P, Thomas L, Reedy G. ‘The Diamond’: a structure for simulation debrief. Clin Teach. 2015 Jun;12(3):171-5. doi: 10.1111/tct.12300. PMID: 26009951; PMCID: PMC4497353.

7 Rudolph JW, Simon R, Dufresne RL, Raemer DB. There’s no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simul Healthc. 2006 Spring;1(1):49-55. doi: 10.1097/01266021-200600110-00006. PMID: 19088574.

8 Abulebda K, Auerbach M, Limaiem F. Debriefing Techniques Utilized in Medical Simulation. [Updated 2022 Sep 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546660/

9 Grant VJ, Robinson T, Catena H, Eppich W, Cheng A. Difficult debriefing situations: A toolbox for simulation educators. Med Teach. 2018 Jul;40(7):703-712. doi: 10.1080/0142159X.2018.1468558. Epub 2018 May 23. Erratum in: Med Teach. 2022 Sep;44(9):I. PMID: 29792100.

10 Simon R, Raemer DB, Rudolph JW. 2010. Debriefing Assessment for Simulation in Healthcare (DASH)© Rater’s Handbook. Center for Medical Simulation, Boston, Massachusetts https://harvardmedsim.org/wp-content/uploads/2017/01/DASH.handbook.2010.Final.Rev.2.pdf