SAFILT: The Foundations for Positive Debriefing

Facilitation and Debriefing 

Debriefing following clinical simulation scenarios is a vitally important activity.  Its aim is to provide a safe and critically constructive place for feedback and for self evaluation to occur. To work well, debriefing requires skilful and sensitive facilitation. Facilitators can play a number of educational roles: As convenors, triggers to discussion, and as ‘devil’s advocate’. They may also have a role in moving learners from directed to self-directed forms of learning as their learning needs change.

• The role of a facilitator can be loosely defined as both a critical educator and co-researcher.
• Parts of the debriefing process through facilitation will require direction and correction of learner’s knowledge and practice. Parts will be to facilitate critical reflection on practice.
• The aim is ultimately transferring responsibility for learning to the learners themselves.

Introduction

Facilitating the debriefing of clinical scenarios is a challenging activity. It involves managing the learning needs of people with differing learning styles, differing expertises and competences, and differing personalities. Finding a balance between sensitive correction, direction, and self evaluative learning is what facilitation should be aiming to achieve.

Debriefing in the clinical simulation setting can be seen as supporting learners in the management of uncertainty. The relationship between facilitator and learner is based more on collaboration and co-inquiry for learning rather than directed or instructional approaches – though these may be appropriate at times within the debrief.

At its most simple, debriefing through facilitation is a way of confronting a subject and of establishing contradictions and possibilities of change that challenge the learner’s world view. The aim of this material is to break down some of the theories and practices that can best support the excellent work already being done in clinical simulation.

Facilitation  
Good facilitation is argued by Brockbank and McGill (2000) to enable collaboration, dialogue, and challenge while maintaining the integrity of the subject specialism. This means that whilst there is an opportunity to pull apart practices and structures, there remains a set of values and principles which maintain the rigour of, in this case medicine or related health professions.  Being able to make distinctions between task (i.e. the task of how we unravel the actions and thinking undertaken in the scenario) and process (the way in which these become unravelled and as such create transformation) is an important element to this. There are differing modes as to how this can be done, and Heron (1993) identifies three main modes of facilitation:

1. Hierarchical, where structure, content and method are controlled by the teacher
2. Cooperative, where there is a sharing of decision making with the learners; and
3. Autonomous, where decisions are taken by the learners
          

ACCESS THE VIDEO FILE FACILITATION_&_DEBRIEFING_1 NOW USING THE BUTTON AT THE TOP RIGHT OF THIS WEBPAGE

In this clip Ian refers directly to the Crisis Resource Management (CRM) points as learning objectives and follows this by throwing out a critical question.  CRM is a term used to refine and implement systems, behaviour and resources to situations that require rapid and collaborative responses.  CRM may also be described as non-technical activities of acute care – what human beings do to effect change in the clinical environment.

These may not be evident to the learner, but are used at the discretion of the teacher to optimise the learning trajectory.

Being competent in all three modes, and being able to use them intentionally, opens up possibilities for supportive and progressive learning and teaching styles adapted as learners become more confident. Intentionality for teaching delivery is one step in the process, leading to these modes as catalysts to intentional dialogue.

Essentially facilitation for learning has two main concerns which underpin it: Task – what is to be done; and Process – how it is to be done (Brockbank and McGill, 2000). Being transparent in how these educational strategies are employed benefits the learner because they will have an understanding as to why the differing modes are being used – a hierarchical mode may be useful to learners recently exposed to a new area of learning, whilst an autonomous mode will be valuable to those with degrees of expertise. What is important is that the learner is aware of the strategy and is then more able to work productively with it, and this has the potential to open up subject related and reflective dialogue.

Debriefing

Pearson and Smith (1996) describe debriefing as ‘that phase in experience-based learning where purposeful reflection by an individual or a group takes place’. (p.70). Further, they suggest that debriefing is not therapy, counselling or encountering, although it is possible that these elements may be present. Neither is it just a ‘chat’ about what happened in the experience. In the case of medical simulation scenarios, as is the case with most other experiential learning, the activity is intentional, purposeful and planned. Debriefing is part of this total learning programme.

Beginnings, Middles, and Endings: Debriefing can be more successful if it is connected clearly to what preceded it. In other words, by supplying a brief, an activity (scenario), and then debrief, the purposes of the activity can be seen much more clearly. In so doing, focus and integration of context is provided as part of the learning activity. Briefing is essentially a form of orientation. It is not about giving the game away, it is about ascribing roles and tasks for the activity itself. Debriefing should be part of the natural progression in attempting to achieve the planned purposes and intentions of the activity and its preceding intended learning outcomes to uncover how successfully this has been achieved. It is important to remember that high fidelity simulation is aiming to do more than consolidate skills and knowledge: it aims to provide a space for situational learning.

This leads us finally to the importance of awareness that the role and context of the debriefer and the participants should change depending on what is being sought as an outcome. If this is not in place, Pearson and Smith (1996) argue that conventional knowledge and emergent interpretive and conceptual meanings are lost in aimless discussion or overly systematic modes of teaching. Roles are therefore fluid. The debriefer may at times need to act as an instructor, or may at times provide important prompts to create dialogue between participants. Participants too may have areas of expertise that they are able to impart to their peers. The point is that a debrief is not a place to provide instruction for its entirety, neither is it a place for aimless discussion: It is a conversation with purpose to share and inform between its members.

Clarity of thinking is therefore important to establish. What is it that you are trying to achieve through your scenarios? Are your outcomes or goals educational or clinical? This may seem slightly chicken and egg, but the question remains ‘are you setting your educational goals first and then building the scenarios to achieve them, or developing the clinically relevant scenarios for (say) FY1&2s first and then building your educational outcomes into them?’

This seems to an extent semantic, but it matters from the perspective of debriefing because if you choose the latter there is the possibility of reliance on clinical knowledge and directed learning in your debrief – at the expense of what can be learned as an educational process.

Debriefing then, is all about balance: The balance of aiding and ensuring clinical knowledge and skill and the balance of experiential learning and development. The weighting of these may (and should) be different; Some learners (FY1 as an example) may require more technical, and therefore directed input, while FY2’s should be more skilled and knowledgeable and as such more able to make better connection and relevance to non-technical activities as being clinically valuable. As an example of goal-setting therefore, if the FY1 and 2 learners are separated out in simulation, debriefing and the scenarios themselves can be geared specifically to their needs. If they are combined, then it is possible in the scenarios and debriefing process that the FY2’s can act more authoritatively and vicariously as educators to FY1 learners.

Referring back to Heron’s (1993) model above, whilst sometimes it may be necessary to set up debriefing in such ways, it may also be possible to combine them, providing an amalgamation of directed learning where necessary (clinical safety), a co-inquiry approach to complexities of practice, (non-technical), and the reaching of coherent and logical conclusions (e.g. ethical, human resourcing, and clinical decision making).

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References

Brockbank A. McGill I. (2000) Facilitating Reflective Learning in Higher Education. Society for Research into Higher Education and Open University Press, Buckingham

Heron J. (1993) Group Facilitation Kogan Page, London

Pearson M. Smith D. (1996) Debriefing in Experience-Based Learning IN Boud D. Keogh R. Walker D. (1996) Reflection: Turning Experience into Learning Kogan Page, London