DOI-10.21304/2016.0303.

00134
Symposium
Debriefing –What, why and how?
Vijayanand Jamalpuri*, Amy Kline**, Mike Shepherd***
*Vijayanand Jamalpuri, Consultant Neonatal Pediatrician, Rainbow Children’s Hospital, Hyderabad, India
**Ms Amy Kline, Simulation Specialist, Minnesota, USA, ***Mike Shepherd, Pediatric Emergency Specialist
Starship Hospital, Auckland, New Zealand
Received:8-Jul-2016 /Accepted:24 Jul-2016/Published online:31-Jul-2016

ABSTRACT
Debriefing is a critical part of a simulation exercise in order to foster reflection and enhance clinical
reasoning. Without a proper understanding of how to debrief simulation based trainings or real life events
can be ineffective and inconsistent. In this article we provide an overview to the necessary elements of
debriefing. We describe a three-stage approach to debriefing; reactions, descriptive and summary and
review different forms of questioning that can be used in the descriptive phase. It is important for educators
in simulation to train and understand how to effectively lead learners through simulation and debriefing in
order to be successful.
Keywords: Reflective learning, directive feedback, delta- plus, Advocacy-Inquiry.

Adults are experiential learners and they learn best compassion, humour etc), which vary among our
when they are actively engaged in the process by real colleagues and in some cases require further training.
time experience. Simulation training or exercises can Secondly, debriefing is a practical skill that requires
provide such experience to the learners. Therefore, training and practice; this article therefore serves
simulation is a technique, not a technology, to only as a theoretical introduction to debriefing.
augment or recreate real experiences. However such
experiences turn into learning only when there is What is debriefing?
a mutually engaging dialogue based on reflection
Debriefing, the process whereby the facilitators and
between the learner and the educator1. Debriefing
the learners reexamine the clinical encounter, fosters
helps in generating such dialogue and highlights
the development of clinical reasoning and judgment
the lessons for learners through guided reflection on
skills through reflective learning processes. The
their performance. This is true for learning from real
clinical encounter could be a simulated one or even
life experiences, but is an even more essential part
a real one2.
of simulation learning. Simulation learning without
The terms ‘‘debriefing’’ and ‘‘feedback’’ are often
debriefing is ineffective, even unethical. A lack of
used synonymously. However, there are important
understanding or skill in debriefing is likely to lead to
distinctions between the two, feedback is defined as
significant variations in practice and missed learning
information about performance which is provided
opportunities following a simulation exercise.
to the learners with the intent to modify thinking or
Therefore, it is a must for the trainers to understand
behavior to facilitate learning and improve future
nuts and bolts of the debriefing.
performance. Thus, feedback is viewed as the one-
We have 2 disclaimers about this article, firstly
way conveyance of information to the learner. In
that debriefing is an art not a science, it relies on a
contrast, debriefing is an interactive, bidirectional,
range of nontechnical skills (eg reflective listening,
and reflective discussion3.
Correspondence
Dr Vijayanand Jamalpuri, Consultant Neonatal Pediatrician,
Why to debrief?
Rainbow Children’s Hospital, Road Number 10, Banjara Hills,
Hyderabad, Telangana 500034 The concept of reflection on an event and subsequent
E-mail: vjamalpuri@[Link], Mobile: +919866157271 analysis is the cornerstone of the experiential learning.

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SYMPOSIUM Debriefing –What, why and how?

Indeed this ability to reflect, appraise, and reappraise simulation exercise took place will help the learners
is considered essential for lifelong learning. In to disassociate themselves from their emotions
practice however, not everyone is naturally capable following the stressful scenario. It may allow course
of analyzing, making sense, and assimilating learning organizers to prepare the simulation room for the next
experiences on their own, particularly those included set of learners. If separate room is not available, one
in highly dynamic team-based activities4. The attempt can debrief away from the scenario area if possible.
to bridge this natural gap between experiencing an
event and making sense of it led to the evolution of How to debrief?
the concept of the “post experience analysis” which is
Facilitator’s role is to maximize the educational
called debriefing4. Debriefing provides opportunities
potential of the debriefing session whilst ensuring
to foster reflective learning.
that it is positive and supportive experience for
Reflective practitioners who engage in introspection
the participants. Therefore it is important to have a
learn to self-correct and assimilate new experiences
structure to the debriefing process. Several debriefing
with prior ones and thus improve their professional
methods have been described2,3,4,5,6,7,8 and we discuss
competence5. The purpose of debriefing is not only
one such method, which consists of three phases:
assimilation of learning but also to transfer learning
reaction, descriptive, and summary. To what extent
to future situations2.
learners engage in the debriefing depends heavily
Creating a safe learning environment: The facilitator on how psychologically safe they feel and on the
must create a supportive and safe environment for the instructors’ facilitation skills3.
learners, to ensure a successful learning experience,
First Phase – Reaction Phase: Learners may be full
in which they feel valued, respected, and free to learn.
of adrenaline and may carry lots of emotions when
Participants should be able to share their experiences
they are immersed in a stressful scenario. Therefore,
in a frank, open and honest manner4. Allowing
first phase of debriefing focuses on exploring the
the participants to be familiar with the simulation
participants’ reactions and the emotional impact of
environment including the mannequins and all the
the simulation experience on them. In this phase,
equipment allays anxiety and creates a better learning
participants can ‘‘blow off steam’’ before completing
environment. A safe learning environment can be
the rest of the debriefing9. Allowing them to vent
achieved with pre-course information about the
their feelings may help them to become receptive and
facilitative learning, explaining the rules of the course
engage fully in the reflective discussion. A common
with emphasis on the same during introductions and
opening questions could be ‘‘how did that feel?’’ or
lectures. For example:
“how did it feel to be in that case?” Facilitator should
• The events of the course are confidential and
listen to the answers carefully to understand what the
individuals’ performance will not discussed
learners want to talk about and thereby their learning
elsewhere.
needs. Information provided from participants in this
• If things go wrong in the simulation exercises the
phase will be important to use later in the debrief.
emphasis is on why rather than whom.
• There will not be any tricks Second Phase - Descriptive Phase: During the
second phase, the focus is on what happened during
the simulation and why participants performed the
How much time for debriefing? way they did9.
One should allocate double the scenario running time Facts: Elicit the likely clinical diagnosis of the
for the debriefing; usually 10-15 minutes for case patient. Let the learners answer and fill the gaps if
scenario and 20-30 minutes for the discussion. needed. Clarifying medical facts allows the learners
to participate in the open discussion, otherwise they
Where to debrief? might keep thinking and guessing about what could
have been potentially wrong with the patient and
Debriefing in a room separate from the one where

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SYMPOSIUM Debriefing –What, why and how?

what the treatment objectives and approach should directive feedback to the participants and fill the
have been. performance gap6. This might be an approach
Analysis and Generalization: Analysis phase forms used for teaching junior doctors and nurses, often
the crux of the debriefing. In this phase the learners mostly focussed on medical understanding.
and the facilitator together analyze both medical and 3. Focused Facilitation using Advocacy with
non-medical factors (human factors), which were inquiry: Rudolph et al5 described advocacy-
identified during the simulation exercise. Different inquiry method to facilitate learners to disclose
strategies have been described for the analysis phase, the reasons about the their actions. An advocacy
which could be learner guided or trainer guided10. is an assertion or observation, whereas an inquiry
Eppich and Cheng6 suggest using learner guided is a question. When pairing the two together,
debriefing if there is enough time and learner has the instructor acts as a conversational scientist,
good insight, and using trainer guided debriefing stating in the advocacy his or her hypothesis, and
if time is short and learner has poor insight. Three then testing the hypothesis with an inquiry7. For
commonly described methods for analysis phase are example, an instructor might say, Dr Rakesh, I
1. Directive Feed Back 2. Plus - Delta 3. Focused heard you raise your voice and shout at your nursing
Facilitation using Advocacy-inquiry. colleague when you were waiting for medications
1. Directive Feedback: Directive feedback is a highly (observation), I am concerned this might have
educator driven approach. Educator does majority affected the team dynamic resulting in even more
of the talking and learners are provided with the difficulty delivering treatment (advocacy) and I
solutions to the identified problems. This is often wonder if you could share your thoughts around
an approach used for more junior staff eg medical why this occurred (inquiry)? So, the facilitator is
students. Providing information judiciously in the using advocacy plus inquiry to elicit the internal
form of directive feedback may be preferred if frames, which guided the learner’s actions. This
time is very short and performance gaps are highly is the generic approach that instructors can use in
technical e.g. not able to use a T piece device in any scenario: notice a relevant result, observe what
newborn resuscitation because the participant never actions led to the result, and then use advocacy-
used it before. Directive feedback can also be used inquiry to discover the frames that produced the
if underlying reason for the deficient performance results (See Figure 1)7. The frames are the answers
is clear e.g. due to knowledge gap when a learner to “Why?” questions and are likely to be much
says I could not remember the steps of the algorithm more broadly applicable to other situations.
for neonatal resuscitation6. In these circumstances, Some examples for advocacy with inquiry
educators can switch to teaching mode eg, show questions are:
how to use T-piece device or revise the neonatal 1. I observed that you did not turn on the warmer
resuscitation algorithm. before baby was born; I am concerned, as you
2. Plus - Delta: Plus- Delta is a partly learner- know, that baby can become hypothermic in
guided approach where learners encouraged this situation (Advocacy) and wonder why you
identifying their performance gaps by asking think this occurred in this instance? (Inquiry).
questions like: what went well/what would 2. Dr Rajesh, I noticed that chest compressions
you do differently? What was easy/what was were not started until 2 minutes after asystole
challenging?6 This technique is well suited if time was identified and I am concerned about
is limited or if the participants did not share their this as delays in starting chest compressions
thoughts or emotions during the reactions phase. can lead to worse outcomes in cardiac arrest
It provides insight as to what topics are important (Advocacy), I am curious to understand why
to participants. Once issues are identified, the this occurred? (Inquiry)
educator either use advocacy-inquiry questions 3. Dr Preethi, I noticed that you took four attempts
to promote more in-depth discussion or give to site a cannula in this infant with shock rather

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SYMPOSIUM Debriefing –What, why and how?

than place an IO, and I am concerned that it dialogue between the learners and the facilitator to
caused a delay in fluid resuscitation in this allow optimal adult learning. It is particularly relevant
shocked patient (Advocacy), can you please tell to simulation based training and is critical to the
us your experience of this situation?? (Inquiry) success of simulation based learning. It should be the
most rewarding and enjoyable part of the simulation
exercise by creating a safe learning environment and
facilitating a reflective learner centric discussion.
Debriefing is however a practical skill that will require
the debriefer to develop experience and expertise,
learning from other debreifer and their learners.

Conflict of Interest: None

Source of Funding: None
Frames are invisible; they are in the minds of learners. Actions
(including speech) are observable. Most results (e.g., vital signs,
References
order/ chaos) are also observable7.
1. David M, Gaba MD. The Future Vision of Simulation in
Once a particular frame is identified, the facilitator Healthcare. Sim Healthcare2007;2:126–135.
2. Dreifuerst KT. The essentials of debriefing in simulation
should ask whether the other learners havehad similar learning: a concept analysis. Nurs Educ Perspect
experiences in real life and what were the strategies 2009;30:109-14.
they had used in the past. Therefore, analytical phase 3. Sawyer T, Eppich W, Brett-Fleegler M, Grant V, Cheng
should include a discussion to generalize lessons A. More Than One Way to Debrief: A Critical Review of
Healthcare Simulation Debriefing Methods. Simul Healthc
learned to real-world context9. Several cycles of 2016;11:209-17.
analysis are done to discuss the various learning 4. Fanning RM, Gaba DM. The Role of Debriefing in
objectives based on needs assessment of the learners. Simulation-Based Learning. Simul Healthc2007;2:115-25.
Facilitator might want to conclude the session once 5. Rudolph JW, Simon R, Rivard P, Dufresne RL, Raemer
all the learning outcomes are achieved. DB. Debriefing with good judgment: combining rigorous
feedback with genuine inquiry. Anesth Clin 2007;25:361–76.
Third Phase – Summary Phase: The third phase is 6. Eppich W, Cheng A. Promoting Excellence And Reflective
a concluding phase. It is focused on distilling lessons Learning in Simulation (PEARLS): development and
rationale for a blended approach to healthcare simulation
learned and consolidating the insights gained during debriefing. Simul Healthc 2015;10:106-15.
the analysis phase. Facilitator might consider the 7. Rudolph J, Simon R, Dufresne R, Raemer D. There’s no such
following examples in the summary phase with the thing as ‘‘nonjudgmental’’ debriefing: a theory and method for
objective of eliciting learner led conclusions: debriefing with good judgment. Simul Healthc 2006;1:49-55.
1. I would like to wrap up our discussion and discuss 8. Jaye P, Thomas L, Reedy G. ‘‘The Diamond’’: a structure for
simulation debrief. Clin Teach 2015;12:171-5.
take home messages
9. Rudolph JW, Simon R, Raemer DB, Eppich WJ. Debriefing
2. What are the take-away messages? as formative assessment: closing performance gaps in
3. Can you summarize the learning points for me? medical education. Acad Emerg Med 2008;15:1010-6.
10. Cheng A, Morse KJ, Rudolph J, Arab AA, Runnacles J,
Eppich W. Learner-Centered Debriefing for Health Care
Conclusion Simulation Education: Lessons for Faculty Development.
Simul Healthc 2016;11:32-40.
Debriefing is a well structured and designed mutual

How to cite this article: Jamalpuri V, Kline A, Shepherd M. Debriefing –What, why and how?. J Pediatr Crit Care 2016;3:54-58

How to cite this URL: Jamalpuri V, Kline A, Shepherd M. Debriefing –What, why and how?. J Pediatr Crit Care 2016;3:54-58.
Available from:[Link]

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SYMPOSIUM Debriefing –What, why and how?

One Page Debriefing Guide6

(Adapted from Eppich W, & Cheng A. Promoting Excellence And Reflective Learning in Simulation
(PEARLS): development and rationale for a blended approach to healthcare simulation debriefing.
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare:
April 2015-Volume10-Issue 2-p 106–115)

Set the Scene: Begin by previewing what the learners should expect from the debriefing period. Review
that the time will be spent first sharing how it felt to be in that situation, then reviewing what happened
during the case and what participants might have managed differently and end with summarizing points
from the case and how they can apply to the real-world.
Remind learners that you want to hear from them during this time and that you would like them to drive
the discussion.

Reactions Phase: “How did it feel to be in that situation?” or “What about that felt (good/bad/chaotic)?”

Description Phase: Medical Facts - “Can someone summarize the case from a medical point of view?”

DESCRIPTION PHASE - Analytical Phase - “Now that we are clear about what happened, let’s talk more
about the case.”
More Time or Good learner Insight Less time or Poor Learner Insight
Learner Guided Debriefing Educator Guided Debriefing

More Time
Focused Facilitation Less Time – Plus Delta (+/-) Short Time - Direct Feedback
Analyze performance related Learner self-assessment and Provide relevant knowledge
to objectives; exploring learner generated objectives or tips to perform the action
frames of reference “What went well?” correctly
“I would like to spend a few “What do you think could “I noticed you {behavior}.
minutes talking about XXX” have gone better?” Next time you may want to try
“I noticed {behavior} and I “What was easy/what was {suggested behavior} because
was concerned/unsure/happy challenging?” {provide rationale}. How does
because {provide rationale}. Close performance gaps using that sound to you?
Can you tell me what you direct feedback
were thinking at this point?”
Use open-ended questions
“Does anyone have anything else they would like to add that we haven’t discussed yet?”
Yes?
No?
Are all Learning Objectives Covered? No?
Yes
Summary: Learner Guided “I would like to wrap up our discussion and discuss take home messages”
or “What are the take-away messages?” or “Can you summarize the learning points for me?”

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