The Master Debriefer Course

Drs Evangeline Lim and Chong Shin Yuet, talk about the virtual Master Debriefer Course held recently by the Debriefing Academy.

(The Debriefing Academy was founded by Drs Adam Cheng and Vince Grant, with faculty from North America, Europe and Singapore and their website is at www.thedebriefingacademy.com)

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First held as an in-person 4-day course in Calgary June 2019, the course has now moved to an online zoom platform. It consists of seven 2.5-hour Saturday morning sessions. 23 participants from Singapore and one from Abu Dhabi (who woke up at 5 am every Saturday morning!) attended the course held from January 9th – Feb 27th 2021.

We found the course a valuable one and strongly encourage anyone who has an interest in debriefing to sign up! The course organisers are happy to conduct another one in the later half of the year if we have another 24 participants from Singapore so do register your interest with me (chong.shin.yuet@singhealth.com.sg) early so that arrangements can be made!

In this article Evangeline and I share some of the topics and nuggets covered during the course to give you an overview. We also hope to start an ACP-wide initiative to introduce clinical event debriefing so that OT and ICU teams who have had a critical event/ near miss can talk about it and glean valuable learning points that can possibly be translated into an action plan to prevent a similar event from happening again, or to make recommendations on how management could be improved, or even just to allow emotions to be vented and shared, possibly reducing psychological trauma.

Over the next few months, a group of us from across all the SingHealth Anaesthesia Departments will be sharing what we learnt during the Master Debriefer Course during ACP Faculty Development CME sessions so that everyone will be equipped with the basic knowledge and tools to conduct team debriefs on his/ her own.It is our hope that clinical event debriefing will be an integral part of the OT/ICU work culture, just like how it has become second nature to do a team brief at the start of the workday.

Words are powerful: they can build up people or tear them down, particularly after things go wrong even in a simulated situation. Many people wonder just how to say the right things in the right way so that growth and learning happen through the experience, whether it is good or bad. In certain instances, when the task seems too daunting, no words are said because it is just easier that way even if it leaves other people feeling down and unsure of themselves as practicing healthcare workers.

Introduction

The Master Debriefer Course run by The Debriefing Academy aims to equip people with the tools, knowledge and skills necessary to “transform debriefing conversations into vehicles of change within healthcare environments”. Even though it is targeted primarily at debriefing in simulated settings, the skills are most certainly transferable to debriefing real- life clinical critical incidents that result in patients suffering serious morbidity or even mortality.

It is a 7-week course, currently held on a virtual platform in a blended learning style that nevertheless manages to engage participants through experiential learning via role play, and facilitated sharing of experiences in smaller virtual breakout rooms.

Debriefing in simulation is a facilitated reflection process that helps learners identify and close gaps in knowledge and skills. It should include active participation from learners rather than just delivery of feedback, a developmental intent focused on helping the learners learn and improve, the discussion of specific events, with input from multiple sources. The debriefer functions as a guide, a facilitator, a mediator and a teacher and should have the flexibility of adopting these different roles based on the learners’ needs.

Psychological safety

Creating a supportive learning environment is the first step for effective debriefing to happen. The importance of an opening prebriefing before a simulation takes place or debriefing happens cannot be over-emphasized. This is when learners are reassured that the session is not about judgment of an individual or team, but about learning so that the performance next round, whether in simulation or real life, will have better outcomes.

Psychological safety is crucial in a learning environment and can be created by clarifying learner’s expectations, committing to confidentiality, being authentic and respectful, being curious in wanting to understand the learner’s perspective, holding the learner in positive regard, appreciating when learners open up and participate in the debriefing, actively listening, normalizing poor performance, acknowledging challenges, inviting feedback and comments after the debrief, and offering emotional support.

The debriefer should channel care and concern for the learners’ well-being. This is demonstrated by choosing to debrief in a private setting, using pauses or mirroring or paraphrasing to convey empathy and active listening, showing respect, and avoiding demonstration of contempt through body language such as eye rolling, or negative words.

Breaches in psychological safety can happen when mutual respect is lost and learners or debriefers start criticizing or arguing with each other or getting upset. This can also be recognized when learners suddenly become quiet and exhibit body language that suggest defensiveness or the lack of engagement with the discussion at hand. Comments like “I’m surprised you did this” or assigning blame convey judgment and can breach psychological safety. Strategies such as pausing, naming the dynamics of what is going on, reframing and apologies are in order to get everyone back to the discussion table.

PEARLS debriefing framework

Scripted debriefing and debriefing frameworks are useful particularly for the novice debriefer. The debriefer needs to be clear about what the learning objectives are, although new ones may emerge in the course of debrief. Scripted debriefing has been used by the American Heart Association in the Pediatric Advanced Life Support course and Advanced Cardiac Life Support course and has been shown to be more effective in increasing learners’ knowledge acquisition and team leader behavioral skills.

The PEARLS (Promoting Excellence and Reflective Learning in Simulation) debriefing framework describes 4 phases:

1. the reactions phase (exploration of how the learner’s feel or think after the event),

2. the description phase (summarizes what happened from a learner’s perspective),

3. the analysis phase, and

4. the summary phase.

Depending on how much time is available, the learner’s stage of development, whether the rationale for the performance gap was clear and which aspect is lacking (i.e. knowledge, skills, or behavioural domains like team dynamics and communication or leadership issues), a strategy is selected. The strategy may be a learner self- assessment approach, a focused facilitated approach, or a direct feedback and teaching approach or a combination of the above. The debriefer should try to cover the learning objectives or topics important to the learner by the end of the session.

The debriefing script provides questions to initiate discussion. For example, for the reactions phase, the debriefer could ask “How are you all feeling or what are you thinking right now?” A question that can be asked during the description phase might be “From your perspective, what were the main issues you had to deal with?”

Depending on the strategy used in the analysis phase, questions might include “What do you think went well and why, and what do you think you would want to change and why” (the plus-delta technique for learner self-assessment). Alternatively, the debriefer could state an observation and wonder why things went a particular way. With a directive feedback approach, the script might go “I noticed you (insert behaviour), next time try (suggest new behaviour), because (insert rationale here).”

Offering the learners an opportunity to highlight other issues they want to discuss before summarizing signals respect and the desire for shared learning. The course also teaches more advanced focused facilitation techniques such as advocacy-inquiry to uncover learner frames and circular questioning to broaden perspectives. The summary script involves either asking the learners to give a take-home message each, or having the debriefer mention the key learning points from the case and subsequent follow-through steps.

Cognitive load

With each debrief, be aware of the cognitive load that is weighing on the minds of the debriefer and the learner because too high a cognitive load can prevent effective debriefing and learning. Prioritization of the key issues that need discussion is important. To mitigate the cognitive load, various strategies can be employed. These include careful planning and preparation to prevent technical hiccups, the use of a debriefing framework, having a co-debriefer and a whiteboard to scribble comments as they come through during debriefing.

Debriefing is an art that can be mastered through deliberate practice with feedback from learners as well as peers, and through self- reflection.

Difficult debriefings

Difficult learning conversations are things that we dread. How do we deal with learners who think they know it all? Or learners who are emotionally upset or angry? Or learners who have no insight into their performance? This course enabled us to practise debriefing in challenging situations and taught us how to use proactive and reactive strategies to bring the debriefing back on track. Difficult debriefing should be viewed not as a challenge but as an opportunity for growth in our debriefing journey.

Words that explore another person’s perspective, that reaffirms we are all on the same page, that convey appreciation, that are inclusive and non-judgmental such as I and we: these have the power to build people up and help them learn. When we are lost for words, there are useful resources and cognitive aids that are available for use. Debrief2 learn is one such website that literally gives you words to use. However, if you truly want to learn the art of debriefing well, the Master Debriefer Course is the one course you will want to take.