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Coaching the Debriefer: Peer Coaching to Improve Debriefing Quality in Simulation Programs

Cheng, Adam MD, FRCPC, FAAP; Grant, Vincent MD, FRCPC; Huffman, James MD, FRCPC; Burgess, Gavin MD, FRCPC; Szyld, Demian MD; Robinson, Traci RN; Eppich, Walter MD, MEd

Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: October 2017 - Volume 12 - Issue 5 - p 319–325
doi: 10.1097/SIH.0000000000000232
Concepts and Commentary
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Summary Statement Formal faculty development programs for simulation educators are costly and time-consuming. Peer coaching integrated into the teaching flow can enhance an educator's debriefing skills. We provide a practical guide for the who, what, when, where, why, and how of peer coaching for debriefing in simulation-based education. Peer coaching offers advantages such as psychological safety and team building, and it can benefit both the educator who is receiving feedback and the coach who is providing it. A feedback form for effective peer coaching includes the following: (1) psychological safety, (2) framework, (3) method/strategy, (4) content, (5) learner centeredness, (6) co-facilitation, (7) time management, (8) difficult situations, (9) debriefing adjuncts, and (10) individual style and experience. Institutional backing of peer coaching programs can facilitate implementation and sustainability. Program leaders should communicate the need and benefits, establish program goals, and provide assessment tools, training, structure, and evaluation to optimize chances of success.

From the Departments of Pediatrics (A.C., V.C., G.B.) and Emergency Medicine (J.H.), Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada; Department of Emergency Medicine, Harvard Medical School, and Center for Medical Simulation, Boston, MA, USA (D.S.), Alberta Children's Hospital (T.R.), Calgary, AB, Canada; and Department of Pediatrics and Medical Education (W.E.), Northwestern Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.

Reprints: Adam Cheng, MD, FRCPC, FAAP, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB, Canada T3B 6A8 (e-mail: chenger@me.com).

The authors declare no conflict of interest.

Formal faculty development around debriefing for simulation educators requires time and financial investment, making it prohibitive for some. As a result, debriefing quality may suffer in programs lacking sufficient resources to support formal faculty development opportunities. Facilitated postevent reflective debriefing discussions represent a key component of simulation-based education to augment future performance, because inadequate debriefings may not promote intended learning outcomes.1 Debriefing has been defined as a “discussion between two or more individuals in which aspects of a performance are explored and analyzed, with the aim of gaining insights that impact the quality of future clinical practice.”1 The quality of debriefing and eventual impact on learning outcomes is highly dependent on the performance of the educator who facilitates the debriefing.

The literature guides educators in terms of debriefing methods,1–12 adjuncts,13–15 and tools16,17 but without robust faculty development strategies18; the potential of these methods may remain unfulfilled. Simulation faculty development occurs in the following formal venues: courses, conference workshops, and structured fellowship programs; although valuable, these events are not accessible to all and do not support reinforcement of skills over time. We offer an alternative for simulation educator faculty development: peer coaching integrated into the flow of teaching that offers opportunities for educators to maintain and expand their skills with minimal impact on existing work commitments.

Peer coaching can transform everyday debriefing sessions into skill development opportunities for educators.19 Unfortunately, these potentially rich “developmental spaces”20 are instead “developmental vacuums,” with most educators leaving the simulation session without points of specific feedback related to their debriefing(s) on that day. Creating a psychologically safe space provides an environment where educators can learn from each other. By embedding peer coaching in daily educational practice, educators may harness this valuable developmental space by capitalizing on these unique learning opportunities. In this article, we provide a practical guide for the who, what, when, where, why, and how of peer coaching for debriefing in simulation-based education.

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DEFINING PEER FEEDBACK AND PEER COACHING

Feedback refers to “specific information about the comparison between… (an) observed performance and a standard, given with the intent to improve performance.”21 When colleagues deliver feedback, we refer to this as peer feedback. In this article, we focus on peer feedback conversations and define the word “educator” as an individual who is receiving the feedback and the word “coach” as an individual who is providing the feedback. Peer coaching is “a form of work-based learning… involving observation of teaching and feedback,”22 where “two faculty members voluntarily work together to improve their approaches”23 to education. Peer coaching involves feedback provided by someone with a similar level of experience, more experience,22 or perhaps even less experience. The peer coaching relationship may be reciprocal, where the two individuals establish a peer learning partnership with similar learning objectives.24Peer coaching involves peer feedback as a proven element of effective faculty development25 but also promotes shared reflection in a voluntary, confidential, and formative format while “learning with a colleague in one's own context.”22

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WHY PEER COACHING?

Reflection on practice driven by peer feedback represents a powerful faculty development strategy.26 Peer feedback promotes reciprocal exchange of knowledge and attitudes and provides opportunity for modeling of desired interpersonal behaviors.27–29 When applied in the context of medical trainees, peer feedback enhances work ethic, communication skills, and teamwork.30–32 Peers tend to provide feedback on behaviors that otherwise might have gone unnoticed by superiors.33 By encouraging respectful interactions between colleagues, peer feedback supports mutual development and builds a culture of professionalism.34–36 Much like simulation-based education took time to gain traction before becoming mainstream, peer coaching for debriefing can become the norm if embraced and implemented in a thoughtful fashion.

The benefits of peer feedback also apply to faculty development for healthcare educators, especially when peer coaches work within a safe learning environment. Peer feedback initiates self-reflection on teaching skills and encourages open discussion among colleagues to identify strategies for effective teaching.37,38 When introduced with clear goals, educators enthusiastically endorse peer feedback, lauding its benefits for improving teaching skills.39 Peer coaching programs benefit both educators and peer coaches by fostering personalized professional development.40,41 By providing a developmental space for individualized feedback, peer coaching programs create a sense of accountability between colleagues while building a community of practice where peers work together to explore and implement new educational strategies.42

The implementation of a peer coaching program for debriefing skills addresses a pressing need for simulation educator faculty development. Clearly communicating the benefits and goals of a peer coaching program helps create a constructive learning environment. Encouraging faculty to provide colleagues with constructive feedback forms the foundation for a culture of transparency, teamwork, and patient safety that ultimately results in the delivery of higher-quality healthcare.43

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WHO CAN BE A PEER COACH?

In its purest form, peer coaches are colleagues with equal levels of training, knowledge, and stature within the healthcare hierarchy. In reality, differences among peer coaches and educators will exist. Power differentials may create tension that threatens psychological safety, which encourages a shared belief among peers that their learning environment is safe for interpersonal risk taking.44 For example, with novice coaches, credibility and acceptance of peer feedback may be influenced by (a) the perceived reliability and accuracy of the feedback, (b) disruptions in power relations and reversal of hierarchy, and (c) generation of competitiveness between colleagues.45 Providing feedback to superiors may impact the psychological safety of the peer feedback environment, making it more difficult for novice coaches to share honest and constructive feedback. In an unsafe environment, novice coaches may consciously withhold constructive feedback to superiors out of concern for retribution. Conversely, senior coaches may widen the power distance by providing feedback to novices if goals and expectations about shared feedback practices remain unspoken. Widening the power distance jeopardizes psychological safety and undermines the viability of a peer coaching program.

To help overcome this issue, we encourage program leadership to communicate the overarching principles of peer coaching, along with the responsibilities and expectations of coaches and educators engaged in the program. We recommend explicit agreement about ground rules that establish a safe learning environment for peer coaches, including the confidential nature of coaching conversations. Program leadership can build trust among educators by establishing key rules adapted from the management literature46: (a) trust of peers is based on recognizing each person's assets and liabilities, (b) all educators have the right to make mistakes, and (c) educators should assume responsibility for learning from mistakes and help others do the same. Setting the stage by building trust helps peers constructively manage coaching conversations that may be perceived as challenging.

At the session level, discussion among peers before peer coaching conversations occur helps clarify individual expectations and flatten pre-existing hierarchy. For example, two colleagues assigned to teach together for a session involving four consecutive simulation scenarios and debriefings (where each person will have a chance to debrief) should meet in advance to clarify the following: (a) all discussions will be confidential; (b) there is mutual respect, with an understanding that both peers have something meaningful to share irrespective of pre-existing hierarchy; (c) peers will maintain genuine curiosity, with the intent of helping each other improve; (d) both peers will be giving and receiving feedback; (e) peer coaching will occur briefly after each debriefing, with more in-depth discussion at the end of the day; (f) feedback should be constructive with the aim of improving debriefing skills and given absent condescending and/or hierarchical tone; and (g) both the coach and educator can propose topics of discussion. Setting clear expectations cultivates a culture of feedback where input from peers is respected, valued, and encouraged.33

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HOW SHOULD FEEDBACK BE STRUCTURED?

Training for Peer Coaching

Structured training in core principles of effective feedback ensures the success of peer coaching programs.47 Effective feedback is specific, informed by accurate and direct observation, and provided relative to explicit standards of performance.48–50 After training, peer coaches are more confident, comfortable,33,36 and thus more likely to engage in an effective peer coaching relationship.

A collective understanding of debriefing principles promotes the successful delivery and acceptance of peer feedback for debriefing. Although debriefing expertise is not necessary to coach peers, shared terminology surrounding debriefing frameworks and methods helps everyone “speak the same debriefing language.” Previous debriefing training may enhance feedback credibility, thus improving the likelihood that more senior colleagues accept constructive feedback from novice coaches. When simulation programs teach a common approach to debriefing, simulation faculty develops a shared mental model about basic debriefing principles, which maximizes success and minimizes problems. Thus, we recommend that coaches and educators receive training before implementating of a peer coaching program.

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Structured Approach to Peer Coaching

A standardized structure and approach facilitate effective peer coaching conversations.33 A common structure enhances familiarity with the peer coaching process, thereby combating anxiety and resistance.36 With reciprocal peer coaching, a standardized approach establishes joint expectations about process, thus promoting a feedback culture.

Peer coaching may take different forms. Targeted peer coaching involves short sessions where specific, focused feedback addresses one or two performance issues. In this context, we encourage feedback best practices. Feedback should be informed by direct observation when possible, focused on how the task could be improved relative to an accepted standard and include rationale for why the task should be performed differently.49,51 Targeted peer coaching may also involve more in-depth learner self-assessment and reflective discussion via focused facilitation.52 For targeted coaching, we encourage preview statements to introduce the topic of discussion, followed by questions that either promote learner self-assessment or focused facilitation. Regardless of method, targeted peer coaching sessions are short, focused interactions with the goal of immediately improving one or two specific debriefing skills.

Debriefing of the debriefing encompasses more in-depth discussion about various aspects of debriefing performance, with educator and coach helping each other improve in a mutually respectful, constructive manner. The debriefing of the debriefing offers an opportunity for coaches to model desired approaches to debriefing; peer coaches should debrief their colleagues using the same approach they would debrief a simulation session. For example, within our simulation programs, we teach educators a blended approach to debriefing healthcare simulation, known as: Promoting Excellence and Reflective Learning in Simulation (PEARLS).2,52,53 Peer coaches also use the PEARLS approach when conducting a debriefing of the debriefing. This includes the selective use of learner self-assessment, focused facilitation, and directive feedback during the debriefing process.2,52,53 By applying PEARLS concepts to peer coaching, coaches model the PEARLS approach and provide opportunities for their peers to reflect critically on their own debriefing performance. Role modeling promotes implicit learning through observations of behaviors and their consequences,54 while it also improves educator self-awareness through reflection on their own behavior.55 This approach to peer coaching makes the debriefing of the debriefing process highly explicit, thus minimizing surprises related to the structure of conversation and contributing to a psychologically safe learning environment.

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WHAT CONTENT SHOULD BE DISCUSSED?

The Role of Debriefing Assessment Tools

The use of criteria-based assessment tools supports effective peer feedback through clear descriptions of target competencies.56 These instruments offer structure for coaches to implement while implicitly delivering peer feedback.57,58 To be used effectively and to minimize the risk of harm, we recommend rater training before using these tools to facilitate the peer feedback process.57,58 When using these tools in a formative fashion, previous training helps raters understand the various elements and behavioral anchors, thus promoting constructive feedback. Without rater training, users of these tools risk making invalid, unreliable, or damaging assessments, thus threatening the effectiveness and safety of the peer coaching process.

Two debriefing assessment instruments exist: the Debriefing Assessment for Simulation in Healthcare (DASH)57 and the Objective Structured Assessment of Debriefing (OSAD).58 By highlighting differences between perceived and actual debriefing performance, these tools serve as valuable resources for coaches when providing constructive feedback related to elements of the debriefing process. The development of the DASH was informed by debriefing best practices derived from an expert panel of simulation educators. The DASH has the following six elements: (1) establishes an engaging learning environment, (2) maintains an engaging learning environment, (3) structures the debriefing in an organized way, (4) provokes engaging discussion, (5) identifies and explores performance gaps, and (6) helps trainees achieve or sustain good performance.57 A DASH rater handbook provides explicit description of desired and undesired behaviors for each of the six requisite elements. The OSAD describes the following eight core components of effective debriefing that were identified via literature review and expert opinion: (1) approach, (2) environment, (3) engagement, (4) reaction, (5) reflection, (6) analysis, (7) diagnosis, and (8) application.58 The DASH and OSAD provide a common language for desirable debriefing practices, helping peer coaches role model corrective behaviors to improve feedback quality.

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Peer Coaching: Debriefing Feedback Form

Although both DASH and OSAD support implementation of peer coaching for debriefing skills, the categorization of elements within these tools may bias the content and flow of discussion toward these particular elements. Some aspects of debriefing, such as co-facilitation, time management, and use of adjuncts (eg, video, debriefing scripts), receive little attention. To assist coaches in identifying and role modeling specific debriefing elements, we have developed a comprehensive debriefing feedback form to support peer coaching.

The feedback form includes 10 debriefing elements: (1) psychological safety, (2) framework, (3) method/strategy, (4) content, (5) learner centeredness, (6) co-facilitation, (7) time management, (8) difficult situations, (9) debriefing adjuncts, and (10) individual style, each supplemented by a list of supportive items to help peer coaches reflect on performance issues related to the specific debriefing elements (Table 1). We developed the debriefing feedback form after a comprehensive review of the debriefing and feedback literature and incorporated lessons learned from debriefing projects completed by our research team.1,2,11,13,16,17 Because the form does not provide behavioral anchors or a rating scale, peer coaches must understand the various debriefing elements/items to use it appropriately. Poor understanding may lead to ineffective or unconstructive feedback that may threaten the psychological safety of the learning environment.

TABLE 1

TABLE 1

When peer coaching is reciprocal in nature, a peer learning partnership evolves where both the coach and the educator contribute to discussion with the aim of improving the debriefing process. The peer learning partnership relies less on the coach's individual expertise and more on the collective expertise of both parties in the coaching conversation. In this sense, a collective understanding of the items on the feedback form helps promote healthy and constructive discussion. In peer learning partnerships,24 the feedback form can be used to jointly identify debriefing issues that are high-value targets for improving debriefing performance.

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WHEN SHOULD PEER COACHING OCCUR?

For feedback to occur consistently, peer coaches should allocate sufficient time within the context of a simulation-based educational session. The timing of peer coaching sessions may impact its effectiveness, with evidence suggesting that efficacy and timing are related to the focus and nature of the task.49,50 Immediate feedback (ie, targeted peer coaching) is well suited to the development of specific skills, whereas delayed feedback (ie, debriefing the debriefer) may be better suited for more complicated concepts or addressing knowledge deficits (Table 2).50

TABLE 2

TABLE 2

When applied to simulation-based education, feedback provided immediately after a simulation scenario could target high-yield debriefing skills (eg, previewing statements, effective transitions, paraphrasing)11 or specific issues related to how the debriefing was facilitated.19 On days with multiple simulation scenarios and debriefing, short peer coaching sessions between scenarios provide educators opportunity to work on specific debriefing skills throughout the day. More in-depth and lengthier peer coaching at the end of the day allows for discussion of more complex debriefing issues such as co-debriefing techniques, managing challenging situations, or analyzing individual lines of questioning.19 Coaches should be aware that the longer the delay between the debriefing and the peer feedback session, the more difficult it may be to provide specific, concrete examples (eg, wording of questions) to anchor feedback. To circumvent this problem, we encourage coaches to keep written notes (or use video) with specific examples of wording and/or phrases used during debriefings that can then serve as the basis for further inquiry during a peer coaching session.53

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WHERE SHOULD PEER COACHING OCCUR?

Creating a psychologically safe context for learning allows learners to engage actively in discussion despite potential threats to their personal or professional identity.59 A quiet and private space for peer coaching will contribute to confidentiality by preventing eavesdropping, which is one variable in creating a psychologically safe learning environment. A separate room away from learners (eg, control room or simulation room after learners have left) ensures a space for confidential discussion.

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IMPLEMENTATION OF PEER COACHING FOR DEBRIEFING SKILLS

Peer coaching has proven benefits for faculty development, but some individuals may feel threatened and be less receptive to peer feedback. We suggest the following steps to facilitate the effective implementation of peer coaching for debriefing skills (Fig. 1):

FIGURE 1

FIGURE 1

  1. Communicate the need and potential benefits of peer coaching. Clearly articulating the need for faculty development opportunities for debriefing and the proven benefits of peer feedback will provide a solid foundation for establishing a peer coaching program.
  2. Establish and communicate program principles, goals, and expectations. The goal of the program should be to develop and improve debriefing skills and to build a community of educators who work together to advance knowledge of effective debriefing practice. The expectation is that constructive feedback will be provided in a safe environment where discussions will remain confidential.22,23
  3. Select debriefing assessment tools and/or feedback form. Debriefing assessment tools and/or feedback form will help ensure that key content areas are covered during peer feedback sessions.
  4. Provide training. Coaches will be trained to provide peer feedback in a respectful, constructive manner using the tools and/or checklists selected by the program.47 In addition, all simulation educators will receive the same debriefing training to promote the program's approach to debriefing.
  5. For individual simulation sessions, educators and coaches should do the following:
    1. Establish confidentiality, mutual respect, and genuine curiosity
    2. Clarify expectations
    3. Review personal objectives and goals
    4. Clarify timing, duration, and location of peer feedback
    5. Determine if feedback will be reciprocal or one-way
    6. Conduct simulation
    7. Conduct peer coaching session
  6. Evaluation. Collecting evaluations of educator and coach experiences within the peer coaching program will inform future revisions to the program.
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CONCLUSIONS

By implementing a peer coaching program, simulation programs are less likely to encounter potential barriers to success, which include lack of goal clarity, perceived lack of benefit, fear of peer feedback adversely affecting relationships with colleagues, and lack of expertise in provided peer feedback.33,34 Future research should explore how peer coaching can be combined with student feedback to promote debriefing skills, as well as potential effects on program culture, educator satisfaction, and patient safety. We hope that consideration of the who, what, when, where, why, and how of peer coaching provides simulation programs with the knowledge required to successfully implement peer coaching as a strategy to improve debriefing performance.

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Keywords:

Debriefing; peer coaching; simulation; education; faculty development; feedback

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