https://youtu.be/FUDh2gh5CvA

In the last reflection we reviewed the foundations of Experiential Learning and the Learning Outcomes Model (Learning Card 1). With the core factors of the Learner, Experience and Environment addressed, the next step is to move the learner through the Experiential Learning Cycle (Do, Reflect, Think, Re-Do, Learning Card 3). The 3D Model of Debriefing takes into account both the learning outcomes model and experiential learning to improve outcomes through learning.

The 3D Model of Debriefing (Learning Card 5) consists of the following phases:

 

DEFUSING:

• Allow the learner to “vent” emotions, struggles, and medical sticking points.

Sets the stage for learning.

• Feelings
• Facts

DISCOVERING:

• Analyze and Evaluate performance through reflection.
• Discover mental models or rationales for specific behaviors through

5 Whys or Advocacy/Inquiry (Rudolph et al., 2007).

• Identify gaps and matches between existing and targeted mental models.

DEEPENING:

• Apply lessons from the simulation. Make connections to practice.
• Cue and create analogies to clinical practice.
• Discuss how the simulation performance relates to the clinical setting.

Dive deeper. Form connections and expand mental models for future use that results in a change in practice.

Defusing – Learning Card 6

The process of defusing allows learners to vent their emotions and ensure everyone has the same facts about the case.

Emotional responses are what make experiential learning so powerful, but also create difficulty for the debriefer. In the neuroanatomy of adult learning, emotions (or any change in body state) enlists the hippocampus in burning new neuronal pathways through the use of norepinephrine. Defusing or venting of emotions help to calm both the physical and psychological reactions to an experience, therefore readying the learner for reflection.

Defusing itself comes from helping providers to deal with traumatic events (Mitchell, 1983) and for many learners, simulation experiences are stressful to the point of being traumatic if not addressed appropriately. Setting the environment appropriately, combined with defusing, helps learners to move forward. In the CISD literature, they use the analogy of a video camera. When a stressful event occurs, the camera ‘pauses’ with that one moment more vivid than anything else. Defusing allows the camera to ‘roll’ again.

The process of defusing is simple, but difficult. The core question is “How did that feel?” Note, the question, “How do you feel it went” is completely different and may not get the same result. The intent of defusing is to allow each learner (both participants and observers) to vent his or her emotions or feelings. It is not intended to be group therapy or a group hug, but the debriefer should be ready for handling the feelings that come out. When debriefers have trouble asking the defusing questions, it is often because of their own discomfort. If the feelings are handled inappropriately in defusing they will come out later in the debriefing, especially as fighting the scenario, the equipment, fellow learners, or even the debriefer.

The second component of defusing is to assure we are all “on the same page” on the facts of the case. The easiest way to do this is to ask for an SBAR (Situation, Background, Assessment, Recommendation) from one of the participants. By using the SBAR format (or other similar handoff procedure), the learner has to focus and practice giving a succinct handoff. The intent of discussing the facts of the case in defusing is that it assures we are all on the same page about the ‘what’ question (i.e. was it a CHF or Pneumonia patient) so that we can focus on the ‘why’ questions in debriefing.

Appropriate defusing (or lack thereof), in addition to setting a psychologically safe environment, may be at the core of why some learners have been scared by simulation. In the author’s own experience, he has seen learners have physical reactions (diffuse hives, vomiting) from even hearing that the learner needs to do a simulation. Learners being scarred by simulations is becoming more common and serve as a cautionary tale for how important psychological safety and defusing is. Debriefers who have learners who have had previous negative experiences may need to defuse the previous experiences (even if they were years before), and/or make accommodations (such as allowing them to watch a simulation in your center to see the difference) before putting a learner into a new simulation.

Discovering – Learning Card 7

With a good defusing complete, the debriefer can now dive into the core of the debriefing; identifying learners’ mental models. Discovering mental models represents the reflective observation (reflection) component of experiential learning (Kolb, 1984). Skilled learners may be able to do reflection on their own, but often a debriefer can speed up the process. Part of the difficulty in self-reflection is that most of our mental models are tacit rather than explicit, so the learner honestly may not know why he or she did what they did until a skilled debriefer helps them through reflection.

The tacit nature of mental models means that the debriefer should not make assumptions about why the learner did what they did, but instead should be curious to find the true ‘Why’. As debriefers, we can only see What, and How a learner performs, the Why comes out during the discovering phase. Debriefers should observe scenarios to look for actions (either positive or negative) that they want to ask learners ‘Why’ questions about. For example, if a debriefer witnesses a medication error (what: i.e. giving epi 1:1,000 instead of 1:10,000), the debriefer then needs to ask why (in this case the learner did not know there was a difference) before ‘teaching’ any content. Teaching in the previous example is different if the learner does not know the different dosing (knowledge/comprehension), versus if the learner thought that the patient needed 1:1,000 instead of 1:10,000 (application).

At the core, debriefing is reflection, and reflection is a process of identifying what worked, and what didn’t, to understand the why behind it. Mental models drive every decision adults make. The intent in asking about mental models is to get to the structure of the mental model and identify the gap between the learner’s current and the ideal mental model. Structures by their nature are below the surface. The What/How is the surface; the Why is the structure; although sometimes we have to ask ‘why’ multiple times to get to the structure.

Figure 3: Surface and Structural Mental Models – Learning Card 14

Skillful questioning is needed to help learners share the structure of their mental models. Advocacy/Inquiry (Rudolph et al., 2007) is an excellent tool to identify mental models (which the authors label as frames), but is outside the scope of this article. The other tool for getting at the structure of a mental model is simply the “5 Whys”. Originally designed by Sakichi Toyoda, and frequently used in Lean, the 5 Whys, is a simple way of getting to the root cause in Lean, but can be used to get to the structure of a mental model in a similar way. Interestingly enough, Lean uses the 5 Whys to get to the process that is broken. The assumption is that the person is not broken, which mirrors debriefing well (assuming the best on the behalf of the learner and trying to identify which connection is missing or wrong in their mental model).

An example of how questioning with the 5 Whys works:

Situation – A Paramedic student has misdiagnosed congestive heart failure as pneumonia (identified in the defusing).

Q: Why did you diagnose this patient as having congestive heart failure?

A: The patient presented with difficulty breathing, productive cough, swollen ankles, and difficulty breathing at night.

Q: Given those findings, help me understand why you chose CHF over Pneumonia as a diagnosis.

A: This patient had nocturnal dyspnea.

Q: Why did the nocturnal dyspnea lead you to a diagnosis of CHF?

A: <pause> Well, last week I treated a patient with pneumonia who also had nocturnal dyspnea.

Q: Why did this patient have nocturnal dyspnea?

A: <pause, then learner bangs his hand on the table> *$!@, that was CHF. This patient lays back; the fluid bubbles up, and he can’t breathe.

In the above case, it only took 4 ‘whys’ for the learner to identify their mental model, and then they were able to shift it (part of deepening) on their own. Debriefers need to be comfortable digging in deeper and not letting the learner stop at the surface.   At the same time, debriefers have to resist the urge to lecture or add facts. In this case if the debriefer had ‘lectured’ about the signs and symptoms of CHF and Pneumonia, the student already knew the facts, he just had to make another connection.

Questioning and listening are the two most important skills for a debriefer. It probably goes without saying that debriefers should ask open-ended rather than close-ended questions. A couple of other guidance points:

• Ask why questions not what. If the learner can answer the question by looking it up in their phone, then they should (as this is what they will do in real life). If you find that your learners can look up questions on their phone that means your questions were about simple facts or the ‘what’ not the why.

• Allow for silence. When a debriefer asks questions, they need to wait for the answer, even if it goes into uncomfortable silence.
• Do not rescue the learner, let their peers come to their rescue, if need be.
• If the learner cannot answer the question, ask another question, or rephrase the original question rather than answering it.
• Intersperse small nuggets of associated knowledge, AFTER the learners have answered the questions and shared their mental models.
• As a rule of thumb, the debriefer (or co-debriefers if there are two) should talk less than 1/3rd of the time, and most of that time should be asking questions. If a debriefer finds himself or herself talking most of the time, they have slipped back into lecturing.

Recognizing structures of mental models is a skill that will build over time, and get easier as debriefers start asking better questions (Learning Card 13). Common follow on to a mental model include:

• A long pause. This often reflects the learner ‘digging in’ to help understand his or her thoughts.
• In my experience (or past experience)… mental models develop through experience. A statement such as this one is letting the debriefer into the learner’s past: “Well, I thought (or was thinking)… As learners become aware of their own thought process (metacognition) and can share it, the structures used become explicit rather than tacit.”
• The ‘ah-ha’ moment. The moment the learner banged his hand on the table was the ‘ah-ha’ moment, when he not only identified his own mental model, but made a shift.

If the learner has done everything correctly, and their mental model is correct, the debriefer needs to help the learner make explicit their tacit knowledge (or gut feel). In this case, the goal is to make sure the learner knows the ‘why’ rather than just ‘got lucky’. Helping the learner “who does things correctly” know their mental model will also help the rest of the class. In some cases, debriefers may not have to dive deeper as the student has already put it together; but in most cases deepening comes next.

Deepening – Learning Card 8

Once the debriefer and learner identify the structure of the mental model in play, the next step is deepening. Deepening reflects abstract conceptualization (thinking) in the experiential learning model, and starts the bridge to active experimentation (re-doing) (Kolb, 1984). In deepening, the debriefer is helping the learner to shift the mental model they discovered into one that can be used in future experiences.

To shift a mental model, the debriefer needs to be able to tell if a concept is missing, or if there is a missing/bad connection. At first this may seem daunting, but it is the core of creating critical thinking, so it is worth the work. To help understand the disconnect, it may be helpful to use concept maps (either physically or as a mental exercise (Novak, 1998).

Figure 3 above, (Surface and Structure of a Mental Model, Learning Card 14) can be taken as a simple concept map. Within Figure 3 the surfaces are different, the structure is the same, with exception of the triangle and the smiley face. The figure is similar to the Paramedic example above. The student was able to see the difference in the structures between patients, and make the shift himself.

As the learner move towards higher levels of expertise, their mental models and concept maps become more detailed (Speicher, Martin & Zigmont, 2013). The result for the debriefer identifying the learner’s disconnect becomes harder. Complete concept maps essentially includes labeling of each link or arrow, to make a sentence. The labeled arrow (or connection) is the ‘why,’ while the concept is a ‘what’. If a learner is missing a concept (what) deepening is simply adding that knowledge onto their mental model. If the learner has the wrong (or no) connection (why), then the debriefer needs to queue the learner to the new connection.

The easiest way to queue a learner to making new connections is to show them a different structural mental model, and ask ‘why’ again. In practice, this is the debriefer sharing their mental model, and asking the learner why they made a different connection. The difficult part may be that the debriefer really needs to know their mental model of practice. All too often the debriefer may be unconsciously competent, while the learner is unconsciously incompetent, meaning neither can clearly state their mental model, or demonstrate the difference (Learning Card 9).

Deepening is a great place to bring in a content expert as a co-debriefer, and as someone who is regularly practicing at the bedside, and may be more aware of their mental models and able to fill in the gaps. In this case, the debriefer can ask the content expert about their mental model, and then queue a discussion between the learner and the content expert at the structural level. It can be difficult to be the learning expert (expert debriefer) and a content expert at the same time. Connecting to learners to practice may be easier when the content expert is ‘newer’ and still in conscious competence rather than having progressed to unconscious competence.

The other alternate at the deepening stage is to give learners expert examples to compare at the structural level. Expert examples may be an actual demonstration, but it can also be evidence-based medicine (EBM), or other research. The challenge is to have the learners look at the ‘why’ rather than the ‘what’ of the article. For example, if the debriefer uses a national guideline for practice as a substitute mental model, the challenge for the debriefer is in having the learner understand the ‘why’ of the guideline rather than just the surface steps.

Diving Deeper

Once the learner has identified the gap in their mental model and shifted their way of thinking, Active Experimentation (re-doing) is the way the learner ‘solidifies’ their new mental model (Kolb, 1984). Often this is where we miss a step in simulation-based education. Ideally, we would have the learner complete another simulation directly after debriefing, but due to logistical issues (time, space, and the number of learners), offering each learner a re-do may be impossible. If it is possible, the best practice would be to have the learner complete a second scenario that has a different surface but the same structure.

The second best option for re-doing is a vicarious experience. If two students went through the initial simulation and six watched, having the two that initially did the experience watch another group go through a similar experience may help. In this case, the learners are going through a mental exercise of what they would do with their new mental model, which is a chance for them to ‘try’ it out.

A third option is to have the learners do a mental exercise to apply their mental model rather than an actual new experience. The exercise is simple and involves asking each learner: “What is one thing you can take away from this debriefing that you can use tomorrow in practice?” Although not ideal, it is better than not re-doing, and a great way to close any debrief.

Conclusion

Learners who are repeatedly making the same mistake (either clinically or in simulation) may be missing one of the four steps of the experiential learning process (Concrete Experience-Do, Reflective Observation-Reflect, Abstract Conceptualization-Think or Active Experimentation-Re-Do), or the learning initiative has not taken into account all areas of the Learning Outcomes Model (learner, experience, and environment). As debriefers, it is our duty to make sure the learners have a safe learning environment and move through the entire experiential learning process.

At the same time, we as debriefers, need to deliberately practice our skills and use each debrief as an experiential learning cycle. Debriefing sessions, especially with a skilled mentor should be part of a debriefer’s regular learning process. Debriefing is an art. At times, it is complex, and at times it is simple. As debriefers build their skill, the process will become more and more enjoyable as each learner provides a new work of art that can be influenced and improved.

Application Experience

Participants: 8-12
Time to complete: 1-2 hours+

Directions: Building skills with debriefing takes time and practice. There are two options for this exercise (depending on learning styles and preference):

1. The facilitator of the class provides an example of a good debriefing first.
2. The students try debriefing first and then are given feedback (and a chance to re-do)

Either way, you will need a basic simulation to be debriefed. Ideally you should use a simulation that the core medical components will be familiar to the participants (so that you are not debriefing medical issues rather than debriefing the debriefing).

Some examples:

• Basic mock code (first 5 minutes) focused on good chest compressions.
• Assisting a patient to find their way through a large hospital. (Have the an actor (or participant) act lost, tell the learner that they have to do 4 laps around the table with the actor to get to their destination) Key debriefing point: communication and building a relationship with a patient.

Break the group into debriefing pairs. Each pair should discuss who will lead and who will co-debrief. Allow the debriefing pairs to start the scenario (set the environment), observe and then debrief the scenario. Learners who are not debriefing or in the scenario can be observers and part of the debrief.
After completing the debriefing pair completes their debriefing, the facilitator who is leading the class should debrief the debriefing. Provide feedback based upon the principles above. (NOTE: Debriefing debriefs can be difficult, be patient and work as a group through any feedback and be sure to not go back and debrief the original simulation).

This part of a series called “Learning That Works” by Jason Zigmont, PhD,  (jay.zigmont@gmail.com). For a video on this topic and more information, visit http://L5.LearningInHealthcare.com. The principles above are part of the core content (Learning Card 5, 6, 7, 8 and 14) of the Foundations of Experiential Learning Manual (available at http://FEL.learninginhealthcare.com ).

References

Damasio, A. (1997) The Feeling of What Happens: Body, Emotion and the Making of Consciousness. London, Heinman

Ericsson, K. A, Charness, N (1997) Cognitive and developmental factors in expert performance, in Feltovich PJ, Ford KM, Hoffman RR (eds): Expertise in Context: Human and Machine. Cambridge, MA, MIT Press

Gentner, D, Holyoak KJ (1997) Reasoning and learning by analogy. American Psychology 52:32-34

Knowles, M. (1985) Andragogy in Action. London, Jossey-Bass

Kolb, D. A. (1984) Experiential Learning. Upper Saddle River, NJ, Prentice Hall

Kolb, A. Y., & Kolb, D. A. (2005). The Kolb Learning Style Inventory – Version 3.1: 2005, Technical Specifications. Haygroup: Experience Based Learning Systems, Inc.

Mitchell, J. T. (1983), When disaster strikes. . . the critical incident stress debriefing process. JEMS 8:36-39

Novak, J. D. (1998). Learning, creating, and using knowledge: Concept maps as facilitative tools in schools and corporations. Mahwah, NJ: Lawrence Erlbaum Associates.

Rudolph, J. W., Raemer, D.B. Simon, R., (2014). Establishing a safe container for learning in simulation: The role of the presimulation briefing, Simulation in Healthcare, 9(6), 336–349.

Rudolph, J. W, Simon R, Rivard P, et al. (2007) Debriefing with good judgment: Combining rigorous feedback with genuine inquiry. Anesthesiology Clinician 25:361-376, 2007

Speicher, T, Martin, M., Zigmont, J. J. (2013) Evidence Based Concept Mapping for the Healthcare Student, Athletic Training Education Journal, Vol. 8, No. 4 pp. 124-130

Zigmont, J. J, Kappus, L, Sudikoff, S.N. (2011a) The 3D Model of Debriefing: Defusing, Discovering, and Deepening. Seminars in Perinatology, April 2011, Vol 35, Issue 2, p. 52-58

Zigmont, J. J, Kappus, L, Sudikoff, S. N. (2011b) Theoretical Foundations of Learning Through Simulation. Seminars in Perinatology, April, Vol. 35, Issue 2, p. 47-51