Debriefing the Interprofessional Team in Medical Simulation

Today, more than ever, effective inter-professional team communication, collaboration, and coordination in the care of patients with increasingly more complex disorders in the fast-paced, dynamic, evolving healthcare environment is paramount.  Inter-professional teamwork is now a worldwide-recognized core inter-professional competency that all healthcare providers should acquire.  Simulation-based training (SBT) is an excellent format for fostering the knowledge, skills, and abilities (KSAs) needed for highly reliable team interaction by bringing together inter-professional learners in a nonthreatening environment in which they can practice addressing high risk, low-frequency situations without any risk to a patient. By doing so, these inter-professional teams can internalize these KSAs to make them automatic in the actual clinical environment. Although the high technology simulators and complex scenarios of SBT tend to focus more attention on its technology, methodology, and curricular components, the ultimate utility of SBT as an educational format relies on the effectiveness of the debriefing rendered during a session. Some authors consider it element of SBT. It is within the debriefing that SBT participants identify their learning gaps and develop strategies for improving them, usually under the guidance of the educator/facilitator leading the SBT session.  Such guidance can be particularly challenging in the setting of an inter-professional team in which, by definition, learners come from different backgrounds and perspectives.   Debriefing has played an integral role in the medical simulation since its implementation, and its advantages are well-founded in educational theory. Debriefing strategies are based upon learner types, scenario objectives, and preference of the educator leading the debrief. Irrespective of technique, debriefing leads to meaningful learning opportunities via experiential reflection. Reflective practice outlines how it is not the experience alone but the deliberate reflection on experience that leads to active learning. When appropriately applied to clinical practice and educationally productive debriefing following medical simulation can inevitably improve patient safety. Medical debriefing is based upon the military and aviation fields, which have team building, crisis management, and high-risk situations in common. Anesthesiology debriefing specifically has its origins within aviation crew resource management (CRM). Military debriefing was developed by Colonel S.L.A Marshall, the chief United States Army historian in World War II, Korea, and Vietnam. He conducted debriefings of the entire military unit immediately following an event. Jeffrey Mitchell, a psychologist, developed the Critical Incident Stress Debriefing (CISD) for civilians, also commonly viewed as the framework for medical debriefing today. CISD is contingent upon its seven phases, including introduction, information discovery, detection of individuals’ thought processes, reaction, symptom description, teaching, and reentry. After repeated plane accidents in the 1960s and 1970s, pilot interviews revealed a lack of adequate training in leadership, decision making, judgment, communication, and crew coordination. When CRM training resulted in improved outcomes for the aviation industry, Gaba et al. developed anesthesia CRM to improve safety in the operating room.   Debriefing can occur either after or during a simulation exercise. It can also be either facilitator-guided or self-guided by simulation learners. Two of the most important aspects of healthcare simulation include debriefing and feedback. The difference between feedback and debriefing is worth clarifying. Feedback is a one-way delivery of performance information to simulation participants with the intent to modify behavior and improve future activity performance. Debriefing, on the other hand, is a bidirectional, interactive, and reflective conversation between facilitator and participant. Of note, the act of debriefing itself is more important than the specific technique utilized. There has been no data to suggest that there is a best or optimal way to debrief, but rather a large variety of techniques available from which simulation educators and experts can choose.