Debriefing for Clinical Learning

Background

Debriefing is an important strategy for learning from defects and for improving performance. It is one of the central learning tools in simulation and is also recommended after a real-life emergency response.

Debriefing is defined as a dialogue between two or more people; its goals are to discuss the actions and thought processes involved in a particular patient care situation, encourage reflection on those actions and thought processes, and incorporate improvement into future performance. The function of debriefing is to identify aspects of team performance that went well, and those that did not. The discussion then focuses on determining opportunities for improvement at the individual, team, and system level.

Debriefings can follow an actual or simulated clinical event, or they may be embedded in simulated events. Debriefing in health care was first developed and most extensively used as part of formal medical simulation programs. Debriefing remains a central learning activity in simulation, and much of the literature focuses on debriefing in the context of postsimulation exercises. Recent work has also described new forms of debriefing during a simulated event ("within-event microdebriefing"), which is followed by repeated simulation practice opportunities to enhance mastery of clinical and teamwork skills. In addition, AHRQ has long incorporated clinical event debriefing into the TeamSTEPPS team training program. Research specific to clinical events debriefing is beginning to provide support for such debriefing to improve team performance, resuscitation, and other emergency response outcomes. Although real-time or near real-time clinical event debriefing can be challenging to implement, it has been identified as an important aspect of effective clinical education, quality improvement, and systems learning. It is important to note that debriefing can be a useful learning tool in cases where things go well, with near misses, and in cases that involve adverse events.

Components of Debriefing

All forms of debriefing have a shared structure that involves setting the stage followed by three phases including description or reactions, analysis, and application.

Setting the stage: To be effective, a debriefing must be conducted in a manner that supports learning. Thus, the purpose is not to identify error and assign blame, but to understand why actions and decisions made sense to clinicians in the moment. Such a focus increases the probability that positive performance can be reinforced and new options can be generated for changing performance that was incorrect or otherwise below the desired standard. This requires establishment of psychological safety for participants regardless of the type of debriefing conducted. Whether engaged in a clinical debriefing lasting 3 minutes or a simulation debriefing lasting 30 minutes, the tone set by the leader and the leader's management of the discussion are both critical to maintaining psychological safety.

Description or reactions: During this phase, the leader generally elicits perspectives from team members about how events unfolded in the clinical situation or simulation scenario and asks them to describe their reactions. Participants should be requested to identify the important issues to address, and the sequence of events should be clarified.

Analysis: In this phase, the leader should codevelop the priorities for discussion with the participants, balancing participant priorities with any other critical safety concerns that were noted during the event. The goal of this phase is to explore clinicians' rationales for observed behaviors, identify and close performance gaps by discussing pros and cons of chosen actions, and determine any modifiable systems issues that may have interfered with performance. Team members must be able to be direct with each other during this phase, and leaders may need to actively facilitate team members sharing what they were thinking and how they were affected by the actions of others.

Application: This phase of debriefing is designed to identify and summarize the main learning points and consider how they can be incorporated into future practice. Explicitly summarizing lessons learned from the scenario or clinical event may help team members recall and apply these lessons in the future.

Tools

Multiple debriefing frameworks, scripts, and tools are available to assist leaders with planning and implementing debriefings. When used with simulation, the planning includes advance decisions about scenario learning objectives, and debriefing often involves expert facilitators with significant experience in reflective inquiry strategies or a synthesis of leader and learner inquiry strategies. Best practices for effective debriefing in medical simulation include preparation that involves subject expertise, facilitation skills, and selection of evaluation measures; supportive engagement of learners during the debriefing; attention to differences of perspective, conflict, and emotion management during debriefing; maintaining an emphasis on teamwork processes; and ensuring group development of solutions to performance problems. For within-event debriefings, opportunities for practicing skills to mastery are offered as well.

Special Considerations for Clinical Events Debriefing

Clinical event debriefing can be challenging to implement due to the uncertainty about when it will occur and the nature of the events to be debriefed; the time pressures of the clinical environment; and team members' variable facilitation skills and experience. Although the clinical time pressures are very real, experts agree that clinical event debriefing can be done quickly and still be effective.

A common and relatively simple approach to clinical debriefing is referred to as "plus-delta." It consists of three questions: (i) What went well? (ii) What did not go well? (iii) What can we do differently or what needs to change to improve care? The simplicity of this format works well for clinical event debriefing, especially when combined with a checklist or structure that helps the team ensure they address important teamwork principles (Box).

Box. Framework for Clinical Event Debriefing

The team should evaluate whether or not they:

Had clear communication
Demonstrated understanding of roles and responsibilities
Maintained situation awareness
Distributed workload effectively
Engaged in cross-monitoring; asked for and offered help when needed
Made, mitigated, or corrected errors

Adapted from the debriefing checklist in TeamSTEPPS 2.0 module Leading Teams.

TeamSTEPPS includes instruction on clinical events debriefing, and Kessler and colleagues provide comprehensive guidance for developing a clinical debriefing program.

Current Context

Much of debriefing in health care occurs as part of simulation activities. Debriefing is a core learning activity for simulation, and much of the research on debriefing in health care has occurred in that context. Educational research strongly supports debriefing as an effective mechanism for promoting adult learning and enhancing skills and team performance. The literature on clinical events debriefing is less robust. Small studies with historical controls have shown improvement in some resuscitation outcomes with clinical event debriefing in emergency rooms and intensive care units. The American Heart Association and the American Academy of Pediatrics recommend clinical event debriefing after cardiac arrest and neonatal resuscitations respectively based on this evidence. Further implementation research and quality improvement work is needed to determine how real-time clinical event debriefing can be more effectively evaluated and more widely disseminated