Written by Karen Hall: Swinburne University

The use of simulators alone does not equate to high quality training and it is the role of feedback and debriefing that enables the learner to integrate their learning experience (Imperial College London,2012). Debriefing provides the process whereby the students develop their clinical reasoning through reflection and metacognition (Mariani, Cantrell, Meakim, Prieto, & Dreifuerst, 2013). It is the tool that links theory to practice and research and enables students to  critically think and to intervene professionally in complex situations (Anderson et al., 2012; Jeffries, 2005). Debrief is elevated to the most important component of the simulation-based learning experience (Decker et al., 2013). Despite debriefing being common practice post simulation, conflicting views exist as to what is most appropriate or best practice.

Type of debriefing

Video-assisted debriefing   once seen as gold standard for debrief may not provide any advantages over facilitator only debrief.   A systematic review by Levett-Jones & Lapkin (2012) found that in 4 out of the 6 randomized reviewed control studies there was no statistically significant difference between facilitator and video assisted debriefing in achieving learning outcomes. Similar results were established in the findings of a systematic review on simulation-based training (Lorello, Cook, Johnson, & Brydges, 2014)

Debrief “in simulation” versus debrief “post simulation”

Overall post simulation debriefing was more effective than the debriefing that occurred during simulation ( Dufene &Young ,2014;Levett-Jones & Lapkin, 2012).

Environment in which the debrief takes place

There is significant evidence that experiential learning causes feelings of anxiety in the learner (Decker et al, 2013) .Therefore it remains important to create a safe environment for participant debrief. (Decker et al, 2013).

It should be made clear that there is an expectation of confidentiality as to the simulation scenarios, the participant’s actions and debrief discussions. Rules of conduct must be clear concerning constructive, honest and respectful feedback. Sufficient time is to be allocated in the early phase of reaction in debrief to elicit emotional and cultural responses (Chung 2013), personal responses and experiential reflections. There is also a need for both participants and observers to be active in the debrief process (Decker et al, 2013).

 This is further supported by Rudolf (2009)  “a psychologically safe environment allows people to share and reflect their feelings, assumptions and opinions as well as to speak up and discuss difficult topics” This can be addressed by stating upfront  that simulation  can be confusing  or developing a contract with rules for engagement and confidentiality (Dreifuerst 2012,p.327; Gardner ,2013). Ideally this should all take place in an area away from the simulation experience (Pivec ,2011).

The person who should facilitates the debrief

 International Nursing Association for Clinical Simulation and Learning (INACSL)  in their best practice guidelines (2011) for debriefing states that the simulation  debrief is to  be done by the person who observes the clinical experience with the aim of  closing  the gap between desired and actual performance (Decker et al., 2013; Edgecombe et al., 2013).

Training of the debrief facilitator

 Debriefing facilitators require skill In both diagnosing learning needs of participants  and the ability to adjust the level of facilitation needed for the group .In order to achieve this they should have formal training and assessment in debrief (Decker et al., 2013). Competency should be validated through input from learners, those experienced in debrief and assessment instruments.              

Identification of learning outcomes

Debriefing should be based on the  pre-set learning outcomes of the simulation experience (Decker et al., 2013).The learning objectives set the expectations for the debrief and define the standard of performance expected of the learner ( Rudolph, Simon, Raemer, & Eppich, 2008)

Method of debrief

Debriefing should be based on a structured framework for debrief. It should allow for progression through the identified phases of debrief: reaction, analysis and summary or other similar phases and frames identified (Decker et al., 2013; Mariani et al., 2013).

Table 3: Debrief Models

Study of models found in the literature based on (Pivec, 2011.,Dreifuerst, 2012., Gardner, 2013.,Lusk,2013)

Model or Author Identified Phases National League for Nursing Simulation Innovation Resource Centre (SIRC) (Anderson, 2008)	Beginning/Introduction/Opening Middle Closing/Summary
The Mayo Clinic Model for Debriefing (Mayo Clinic, n.d.)	Experience Reflection Conceptualization Experimentation
Plus-Delta (Decker, 2009, Jeffries, 2010)	What went well What would like to change How to change
Advocacy-Inquiry (Decker, 2009, Jeffries, 2010)	Statement of observation followed by probing question of inquiry/why?
Lederman (1992)	Systematic reflection and analysis Intensification and personalization Generalization and application
GREAT (Owens and Follows, 2006)	Guidelines Recommendations Events Analysis Transfer
Fanning & Gaba (2007)	Description Analogy/analysis Application
Dreifuerist (2010)	Engage Explain elaborate Evaluate extend
3D Model of Debriefing (Zigmont, Kappus, & Sudikoff, 2011)	Defusing Discovering Deepening
SHARP Edgecombe ,K., Seaton, P., Monahan, K., Meyer, S.,  La Page  ,S., &  Erlam, G,2013	Set learning goals , How did it go,: Address concerns, Review learning points, Plan ahead future practice

Conclusion and best practice guidelines

In summary best practice for debrief has been graded using the Joanna Briggs hierarchy of evidence (2014).

• Debriefing after simulation based learning for health care students  leads to the significant increase in the  confidence of their  ability to care for the unstable patient (Buckley et al., 2012; Dufrene & Young, 2014)(Level 4d and Level 1b)
• Facilitator only debriefing is as effective as facilitator and video assisted debriefing in achieving learning outcomes (Levett-Jones & Lapkin, 2012, 2013; Lorello et al., 2014; Reed et al., 2013)(Level 1a,Level 1b,Level 2c)
• Debriefing is more effective when it immediately  follows the simulated clinical experience  in terms of knowledge and confidence (Dufrene & Young, 2014; Levett-Jones & Lapkin, 2012)(Level 1b,Level 1a)
• There is a need to create a safe environment and confidentiality for debriefing to be effective in simulation based learning.(Decker et al., 2013; Dreifuerst, 2012)(Level 5b,Level 2d,)
• The debrief facilitator  should be formally trained in debriefing (Decker et al., 2013; Dufrene & Young, 2014) .(level 5b,level 1a)
• The debrief facilitator’s competency should be assessed through input from learners, practice in simulated environments and assessment instruments (Decker et al., 2013; Gardner, 2013)(level 5b,Level5b)
• The person who observes the simulation should be the person who facilitates the debrief. (Decker et al., 2013; Dufrene & Young, 2014; Edgecombe et al., 2013)(Level 5b,Level 1b ,Level 1b)
• Debriefing should be based on the pre-set learning outcomes.(Decker et al., 2013; . Rudolph et al., 2008;  Rudolph et al., 2013)(Level 5b,level 5b)
• Debriefing should be based on a structured framework, however researchers differ about which framework is most effective (Decker et al., 2013; Dreifuerst, 2012; Gardner, 2013; Mariani et al., 2013; Jaeger,2012) (Level 5b,level 2d,Level 5c,Level 2c Level 1b)

References

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Chung,H.S.,Dieckmann,P.,Saul,B.I.(2013). It Is Time to Consider Cultural Differences in Debriefing.Society for Simulation in Healthcare 8, 166-170.

Decker, S., Fey, M., Sideras, S., Caballero, S., Rockstraw, L., Boese, T.,  Borum, J. C. (2013). Standards of Best Practice: Simulation Standard VI: The Debriefing Process. Clinical Simulation in Nursing, 9(6), S26-S29.

Dufrene, C., & Young, A. (2014). Successful debriefing — Best methods to achieve positive learning outcomes: A literature review. Nurse education today, 34(3), 372-376.

Edgecombe,K., Seaton, P., Monahan, K., Meyer, S., LaPage, S., & Erlam, G.  (2013). Clinical Simulation in Nursing:A literature review and guidelines for practice. Aotearoa: AKO National Centre for tertiary teaching excellence.

Gardner, R. (2013). Introduction to debriefing. Seminars in Perinatology, 37(3), 166-174. doi: 10.1053/j.semperi.2013.02.008

Health Workforce Australia, H. W. (2010). Use of simulated Learning environments(SLE)in Professional Entry Level Curricula of selected professions in Australia.  Adelaide: HWA.gov.au Retrieved from http://www.hwa.gov.au/sites/uploads/simulated-learning-environments-2010-12.pdf

Imperial College of London(2012).The London handbook of debreifing.London:National Health services.

Kelly, M. A., Hager, P., & Gallagher, R. (2014). What Matters Most? Students' Rankings of Simulation Components That Contribute to Clinical Judgment. Journal of Nursing Education, 53(2), 97-101. doi: http://dx.doi.org/10.3928/01484834-20140122-08

Levett-Jones, T., & Lapkin, S. (2012). The effectiveness of debriefing in simulation-based learning for health professionals: A systematic review. 2014.

Levett-Jones, T., & Lapkin, S. (2013). A systematic review of the effectiveness of simulation debriefing in health professional education. Nurse education today.

Lorello, G. R., Cook, D. A., Johnson, R. L., & Brydges, R. (2014). Simulation-based training in anaesthesiology: a systematic review and meta-analysis. British Journal of Anaesthesia, 112(2), 231-245. doi: http://dx.doi.org/10.1093/bja/aet414

Mariani, B., Cantrell, M. A., Meakim, C., Prieto, P., & Dreifuerst, K. T. (2013). Structured Debriefing and Students' Clinical Judgment Abilities in Simulation. Clinical Simulation in Nursing, 9(5), e147-e155. doi: http://dx.doi.org/10.1016/j.ecns.2011.11.009

Pivec,  C. R.J, (2011). Debriefing after simulation:Guidelines for Faculty students. (Master of Arts in Nursing), St Catherine University, St Paul,Minnesota. Retrieved from http://sophia.stkate.edu/cgi/viewcontent.cgi?article=1013&context=ma_nursing&sei-redir=1&referer=http%3A%2F%2Fwww.bing.com%2Fsearch%3Fq%3Ddebriefing%2520after%2520simulation%2520guideline%26FORM%3DTSHPLB%26PC%3DMATP%26QS%3Dn#search=%22debriefing%20after%20simulation%20guideline%22  (14)

Reed, S. J., Andrews, C. M., & Ravert, P. (2013). Debriefing Simulations: Comparison of Debriefing with Video and Debriefing Alone. Clinical Simulation in Nursing, 9(12), e585-e591. doi: http://dx.doi.org/10.1016/j.ecns.2013.05.007

Rudolph, J. W., Simon, R., Raemer, D. B., & Eppich, W. J. (2008). Debriefing as Formative Assessment: Closing Performance Gaps in Medical Education. Academic Emergency Medicine, 15(11), 1010-1016. doi: 10.1111/j.1553-2712.2008.00248.x

Rudolph, J. W. P., Foldy, E. G. P., Robinson, T. R. N., Kendall, S. M. A., Taylor, S. S. P., & Simon, R. E. (2013). Helping Without Harming: The Instructor's Feedback Dilemma in Debriefing-A Case Study. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 8(5), 304-316.