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Concepts and Commentary

A Conceptual Framework for the Development of Debriefing Skills

A Journey of Discovery, Growth, and Maturity

Cheng, Adam MD, FRCPC; Eppich, Walter MD, PhD; Kolbe, Michaela PhD; Meguerdichian, Michael MD; Bajaj, Komal MD; Grant, Vincent MD

Author Information
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: February 2020 - Volume 15 - Issue 1 - p 55-60
doi: 10.1097/SIH.0000000000000398
  • Free

Abstract

Debriefing comprises an integral component of simulation-based education,1–4 and evidence also supports its utility after real clinical events.5,6 Despite its importance, debriefers may find themselves ill-equipped to debrief effectively, to the detriment of both clinicians' learning and patient care.7–10 The debriefing literature mostly emphasizes debriefing frameworks and methods, with little discussion detailing how debriefing skills develop over time.1–4,11,12 As a result, simulation faculty development concentrates primarily on foundational skills, such as structuring a debriefing and using specific conversational techniques.2,4,12–21 This relatively narrow focus on debriefing skills neglects the trajectory through which educators develop these skills. Existing debriefing assessment tools provide limited guidance because they do not shed light on how to support debriefers' development from novice to expert performance.22–25 An elaboration of this trajectory would inform simulation education and clinical practice.

A conceptual framework of debriefing skill development would aid understanding of how educators could effectively acquire these skills over time. Conceptual frameworks help shape thinking and ways of viewing complexity by emphasizing the interrelatedness of relevant variables and outcomes.26 Existing theories, models, observations, experiences, and evidence-based practices inform conceptual frameworks. A conceptual framework of debriefing skill development would help shape thinking and clarify key problems and, in doing so, guide future opportunities for research.26

This article has several aims. First, we describe a novel conceptual framework for debriefing skill development based on a modified version of the Dreyfus and Dreyfus model of skill development.27–29 Second, we propose the following 3 stages of debriefing skill development: discovery, growth, and maturity, and highlight requisite characteristics, knowledge, and skills within each stage. Lastly, we describe faculty development strategies to support skill acquisition as they relate to the 3 stages of debriefing expertise and the development of adaptive expertise.30,31 We believe that the conceptual framework will illuminate key concepts in the development of debriefing expertise that will contribute by shaping future faculty development initiatives, research, and innovation in debriefing.

APPLYING THE DREYFUS AND DREYFUS MODEL TO DEBRIEFING EXPERTISE

In formulating a conceptual framework for the development of debriefing skills, we drew from our collective experience as simulation educators and researchers working in academic institutions across North America and Europe. Based on our experiences in teaching and mentoring simulation educators for the past decade, we reflected on the trajectory of debriefing skill development across a healthcare simulation career. Whenever available, we used empiric evidence about debriefing practice to inform elements of the framework.

Our conceptual framework of debriefing skill development builds on the Dreyfus and Dreyfus model27–29 of skill acquisition and integrates our collective observations, experiences, and evidence-informed practice. The Dreyfus and Dreyfus model describes 5 developmental stages of skill acquisition and proposes that individuals draw on prior experiences to progress through each stage and reach higher levels of expertise.27,28 Scholars in nursing32–34 and health professions education35,36 have applied the 5 stages—novice, advanced beginner, competence, proficiency, and expertise—to characterize learners as they progress through training. However, we find that this 5-stage model has limitations when applied to debriefing. Specifically, many educators bring prior skills that translate over to debriefing, making it difficult to situate some educators in one of the 5 stages because they are relatively narrow in scope. To address this issue, we have adapted the model by aligning concepts described within the 5 stages27,28,32 to 3 stages of debriefing skill development (Table 1):

TABLE 1
TABLE 1:
A Conceptual Framework for the Development of Debriefing Skills27,28,36–39
  • The discovery stage: merging of novice and advanced beginners
  • The growth stage: competence
  • The maturity stage: merging of proficiency and expertise

We believe that a 3-stage model better articulates the development of debriefing skills. Our observations suggest that prior experiences as an educator may influence the timing and order in which debriefing skills are mastered. Educators new to debriefing will have varying degrees of experience as teachers, with some skills transferring easily to debriefing (eg, small group facilitation). Other skills critical to effective debriefing, such as social skills and communication skills, may be innate to some educators, who may find it easy to apply these skills organically when facilitating a debriefing. Educators with significant prior relevant experience and skills may find themselves further along the trajectory of development.

Organizing the conceptual framework into 3 stages has several practical advantages. First, having 3 stages instead of 5 provides the flexibility necessary to accommodate for the complex nature of debriefing skill acquisition, which is in part dependent on prior experiences as an educator. We have noticed that some educators in the early stages of debriefing skill development exhibit features of both the novice and advanced beginner stages. Some educators naturally demonstrate skills characteristic of advanced beginners (eg, some capacity to manage complexity), despite being novice debriefers who are acquiring basic knowledge of key debriefing concepts. Similarly, seasoned educators on the opposite end of the spectrum occasionally demonstrate some expert stage skills (eg, making intuitive decisions) while otherwise clearly being situated in the proficient stage (eg, linking process with learning and patient outcomes). Second, we anticipate that educators can more easily situate themselves and their trainees within one of the 3 stages, thus making areas for improvement more transparent. Lastly, we adhere to the “rule of three” described by Booker,40 which proposes that content is easier to follow, understand, and apply when presented in threes—an important consideration if the framework is to be embraced and disseminated in the healthcare simulation community. In this article, we provide brief vignettes to illustrate the conceptual framework, by characterizing debriefers within each stage, and outline specific knowledge and skills that comprise each developmental stage (Table 2).

TABLE 2
TABLE 2:
Knowledge and Skills for the Development of Debriefing Expertise

THE CONCEPTUAL FRAMEWORK FOR THE DEVELOPMENT OF DEBRIEFING EXPERTISE

Discovery Stage

Keisha is a physician who loves to teach. She recently took a 2-day basic simulation educator course and learned a structured debriefing framework. When debriefing, she adheres tightly to the phase-based framework from the course with the aim of addressing case learning objectives. She attempts to uncover rationale for behaviors by posing questions and using suggested lead-in phrases. Unfortunately, this approach often does not yield the desired conversations. She approaches debriefings with a list of items to cover; when learners take conversations off topic, she becomes anxious and quickly redirects discussion to her own objectives. She often finds it difficult to listen and process conversation, identify learning points, and prioritize topics. Despite using debriefing scripts, she often feels cognitively overloaded, which leads her to abandon what she has learned about debriefing and revert to didactic teaching. When learners react emotionally, she typically ignores the issue as she lacks the skills and confidence to manage difficult conversations.

Debriefer Characteristics, Knowledge, and Skills

During the discovery stage, debriefers acquire the foundational, declarative knowledge of key debriefing concepts, such as the evidence for and benefits of debriefing,1,2,12 importance of a debriefing framework,2,4,14,15,18–22,41,42 educational/conversational strategies,2,12,13,16,17,20,43 and psychological safety44,45 (Table 2). During this stage, educators view debriefing as a task broken into a series of concrete steps (Table 1). According to Dreyfus and Dreyfus,27,28 novices apply rules and driving principles strictly with little room for flexibility. Similarly, educators new to debriefing initially use conversational strategies independent of learning context and address topics, issues, and challenges analytically. They may struggle linking certain conversational approaches with the ensuing outcome, resulting in difficulty identifying opportunities for improvement. With sufficient experience, debriefers increasingly generalize certain rules to other contexts and apply them less rigidly, but remain challenged to manage complex debriefings. Although debriefers may recognize some situational aspects of debriefing, they may still lack the skill and flexibility to adapt “on the fly.” An overemphasis on debriefing process limits attention to the primary objective of debriefing, namely, learning as the outcome of debriefing.

Growth Stage

Priya is a respiratory therapist who took her basic simulation educator course 5 years ago. Since then, she has taught several times a month and has had supplemental training at workshops. Based on these experiences, she strives to tailor the debriefing strategy to the learning context. She understands why it is important to consider the learner perspective during debriefing, so she works hard to address issues that learners bring up during discussion. When co-facilitating with physician colleagues, she methodically reviews expectations with her co-debriefers to ensure that they do not interrupt each other. She strives to appreciate how emotions influence learning, and attempts to undercover and explore learner emotions by deliberately using specific techniques. Despite her broad base of debriefing knowledge, she at times feels overwhelmed during debriefing. She understands how a learner-centered approach may be more valuable for learning; however, she still finds it challenging to manage learner needs, emotions, cultural considerations, and co-facilitator expectations while independently trying to self-reflect on her own performance.

Debriefer Characteristics, Knowledge, and Skills

During the growth stage, debriefers work toward acquiring a good declarative knowledge of foundational debriefing concepts and educational strategies applied in context,19,20 along with a growing toolbox of strategies to manage more complex debriefing interactions. This repertoire includes knowledge of co-facilitation strategies,46 tools to manage rapport and difficult conversations,47,48 balancing learner versus instructor centeredness,49 use of objective data during debriefing (eg, video, data from simulator),50 and considerations about cultural influences on debriefing51,52 (Table 2). By the end of the growth stage, debriefers have become “routine experts,”53 drawing on their knowledge and skills to perform efficiently in common situations by recognizing patterns of conversation; however, the myriad of elements encountered during a debriefing can overwhelm these educators. When faced with uncommon or complex challenges, they still rely on rigid analytic reasoning and struggle to adapt. For example, when confronted with strong emotional reactions, such as crying, debriefers at this stage may manage the situation by validating and normalizing these reactions. However, if additional learners became defensive and argumentative, this more complex pattern (ie, 2 upset participants) poses unfamiliar challenges. Debriefers in the growth stage increasingly appreciate the relationship between process and outcomes, viewing debriefing process as a means to achieve improved learner and patient outcomes.

Maturity Stage

Jonathan is the most senior simulation nurse educator in his program, with more than 10 years of experience debriefing interprofessional simulation sessions across a spectrum of learners. He has developed a robust toolbox of strategies with which he reliably manages any type of dynamic situation. He applies these strategies intuitively while adjusting the flow of discussion seamlessly to balance both learner and instructor priorities. Jonathan recognizes triggers for difficult debriefing situations and deals with them by either pre-empting the situation proactively or reactively in an effective and authentic way. His focus remains on the knowledge, skills, and attitudes learners require to impact patient care in the real clinical environment. He also regularly facilitates clinical debriefings on the unit. These conversations help him see how simulation affects patient care at the bedside, while simultaneously providing opportunities to apply, reflect on, and refine his debriefing skills in a high-stakes, clinical environment.

Debriefer Characteristics, Knowledge, and Skills

During the maturity stage, debriefers demonstrate comprehensive knowledge and deep understanding, which they apply in a variety of debriefing contexts. Debriefers solve problems intuitively based on the specific situation, drawing on a vast array of prior experiences. With sufficient experience and faculty development opportunities, they move from routine to adaptive expertise, embracing complex, evolving, and dynamic situations as learning opportunities and relying on adaptive expertise when common solutions are not applicable. Adaptive expertise arises from the efficient application of existing knowledge and serves as a springboard for innovative problem-solving.31,54 Adaptive experts recognize when a routine approach is not working, reframing the problem to allow for exploration of new concepts.53 For example, mature debriefers are adaptive experts who can efficiently generate novels solutions when encountering uncommon, complex debriefing situations. Debriefers strive to go beyond how debriefing improves learner knowledge and skills to see the how debriefing influences both culture and clinical care at an organizational level (Table 1).

FACULTY DEVELOPMENT STRATEGIES

Our framework for debriefing skill development, with the goal of achieving adaptive expertise, has implications for how we train simulation educators. Approaches that foster the cognitive skills of critical thinking and reflective practice will promote the acquisition of adaptive expertise.53 Critical thinking is the process of conceptualizing, applying, synthesizing, and evaluating information gathered from prior observations and experiences,55 whereas reflection is the metacognitive process that occurs before, during, or after experiences with the purposes of developing a greater understanding of the situation.56 Concrete debriefing experiences form the foundation of an effective faculty development strategy, because they provide opportunities for debriefers to practice new skills and master existing ones by stimulating critical thinking and reflection on performance. Ideally, the combination of on-going debriefing practice and faculty development strategies facilitates efficient progression from one debriefing stage to the next. A recent systematic review of faculty development in medical education highlights the role of a multifaceted approach: courses and workshops, peer feedback, self-reflection, mentorship, and deliberate practice.57 We now propose how these (and other additional) strategies fit within the 3 developmental stages to support acquisition of debriefing skills (Fig. 1).

FIGURE 1
FIGURE 1:
Faculty development strategies to across 3 stages of debriefing expertise.

In the discovery stage, exposure to foundational training introduces educators to key declarative debriefing knowledge: concepts, frameworks, and educational strategies. Tools or cognitive aids offer scripted language and a stepwise approach to debriefing that supports the rule-based, algorithmic approach most debriefers initially follow.20,58,59 Prior research supports the effectiveness of debriefing scripts for novice debriefers to improve learning outcomes in pediatric resuscitation.60 In this stage, debriefers may manage their cognitive load by relying heavily on scripted language to formulate questions that drive discussion.61 As Dreyfus27 notes, improvement in this stage requires “monitoring, either by self-observation or instructional feedback.” Self-assessment through self-observation and reflection may include reflecting on debriefing practice through video review.62 Debriefers may also receive feedback from students, peers, or experts,22,63 which may activate critical thinking. Peers may provide immediate, workplace-based feedback and coaching, but the quality of this feedback is highly dependent on the peers' expertise.64 Mentors who provide regular expert feedback reinforce guiding rules (eg, adhering to a debriefing framework) while encouraging positive behaviors that demonstrate increasing ability to adapt to contextual factors.

A number of factors support learning during the growth stage. Additional training in the form of courses and/or workshops supports the expanding breadth of debriefing knowledge and skills. This may be further complemented by observing, co-facilitating with, and learning from experts.65 Reflection becomes a key strategy, in particular by means of contrasting multiple perspectives (eg, debrief, being debriefed, observing debriefing),10,66,67 as this promotes self-reflection and the critical thinking required to develop adaptive expertise.53 Debriefers rely less on debriefing tools to execute basic debriefing skills (eg, phased-based debriefing) but may still use them to support the acquisition of more advanced skills, such as managing difficult debriefing conversations that add complexity and increase debriefer cognitive load.61 As debriefers become more skilled, they depend less on abstract principles and rely more on their own concrete debriefing experiences.28 Peer feedback and expert mentorship remain important strategies to extract learning from debriefing experiences. Providing peer feedback promotes critical thinking and analysis of debriefing performance and may even encourage self-reflection.63 In the growth stage, debriefing experiences should be varied in context (ie, different learner groups and environments), which promotes the application of rules in different contexts.

When debriefers reach the maturity stage, they amass a breadth of knowledge, skills, and experiences such that “each specific situation immediately dictates an intuitively appropriate action.”28 Mature debriefers require continued exposure to a variety of contexts, supplemented by peer feedback and self-reflection, to ensure the continued development of skills to construct novel solutions to rare challenges (ie, adaptive expertise). On-going practice coupled with feedback is required to prevent skill decay. Additional training targeted to specific needs might further promote development and maturity. By providing peer feedback, debriefers in the maturity stage help build a community of practice that supports faculty development within programs, while concurrently reinforcing skills that they are likely performing with unconscious proficiency.

DISCUSSION

An organized approach to faculty development that considers the various stages in the conceptual framework that we have proposed helps promote the effective acquisition of debriefing skills. Enriching experiences help highlight performance deficits, fill knowledge gaps, and enhance an individual's appreciation for the complexity of the debriefing process. For example, we have observed that some educators come to their initial debriefing instructor course showing confidence but relatively lacking in debriefing skills. After taking the course, educators often have a greater knowledge of and appreciation for the complexities of debriefing, while concurrently experiencing increased cognitive load that may negatively affect their ability to progress as a debriefer.61 Longitudinal faculty development opportunities that target individual learning needs may help educators manage their cognitive load, while activating critical thinking and self-reflection, which promotes the development of adaptive expertise. Educators who lack exposure to sufficient faculty development opportunities run the risk of being too rigid in their approach to debriefing, which may affect the impact of the debriefing on learning and clinical outcomes.

Although our proposed conceptual framework has several strengths, it also has several limitations. We have modified Dreyfus and Dreyfus' original 5-stage model of skill acquisition and adopted a 3-stage model. Some may argue that this challenges the validity of our conceptual framework. Our observations support a 3-stage model, which represents a better fit for the skill of debriefing, which is influenced by prior educator experiences and conversational skills. In reality, educators may not acquire the knowledge and skills we have described in such a linear, stage-based manner. Educators may straddle stages (or “jump” back and forth between stages) as they acquire some of the skills in one stage (eg, managing difficult conversations in growth stage), while fine-tuning skills from a different stage (eg, maintaining psychological safety in Discovery Stage).27,34 Progression through the 3 stages (and the amount of time spent in each stage) likely varies from educator to educator and is dependent on the nature and quality of faculty development opportunities.

As simulation-based debriefing research is in its nascent stages, much of what is considered “standard of practice” in debriefing is based on existing theoretical frameworks,16,17,68 adaptation of strategies from other fields,13,42,49 and practical solutions that fit existing needs.15,20,21 Similarly, our conceptual framework offers an illustrative and practical model of viewing debriefing expertise that serves to inform faculty development strategies and future research.

IMPLICATIONS/SUMMARY

In this article, we introduce a new conceptual framework for the development of debriefing skills based on Dreyfus and Dreyfus' model of skill development. The conceptual framework is supported by observations, best practices, evidence, and expert opinion. By highlighting the characteristics, knowledge, and skills of debriefers in each stage, we provide a roadmap of skill development to stimulate future research and innovation. In particular, our field would benefit from work exploring the impact of different faculty development strategies on debriefing skill acquisition and retention. Based on our conceptual framework, we provide educators scaffolding for self-reflective activities and to help them identify opportunities and strategies for improvement. We hope the conceptual framework will stimulate further dialog in the simulation community that will shape the future of debriefing faculty development.

ACKNOWLEDGMENTS

The authors thank Dr. Victoria Brazil for providing feedback on earlier versions of the manuscript that helped shape the final product.

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        Keywords:

        Debriefing; Expertise; Conceptual framework; Faculty development

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