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Q: Our simulation center is pushing us to include more video in our debriefings. How would you recommend the process on using video with Debriefing with Good Judgment?

In our center’s model, we would say, “Watch Dr. X when she enters the room,” we would show the video, and then say something like, “So, Dr. X, what did you think about your communication when you entered the room?” Through a series of questions, they would try to extract the “why” and then generalize. In practice, I think this ends up triggering defensiveness. What do you think about this?

Thanks so much!

A: When I hear this question, I reflect to when I believed that learning was obviously better if the learner came up with the answer themselves. I now realize that sentence only applies to frames. How important is it that the learner come up with what I am thinking? If it is a specific knowledge point (e.g. Naloxone is the reversal agent for MSO4) it might be true. But if it is about why they didn’t give the Naloxone when they certainly understood its use, it is likely to be much more complicated. If I take the leading question approach, I might not learn anything about why they did not give it. However, I am likely to hear, “Oh right, I should have given Naloxone to reverse the opioid.” I can certainly follow up with “Why didn’t you?” but I risk a lot of defensiveness. So, I don’t buy the argument for GWIT (Guess What I’m Thinking) questions anymore! I’ve often wondered where this belief comes from. In my experience, being obtuse and expecting them to guess leads to disengagement and defensiveness, neither of which enhance debriefing. So why risk it? Just tell them what’s on your mind! Ultimately, the goal is for us to understand their thought processes, not for them to guess ours.

Using the With Good Judgment approach is 1) less confusing to learners because you as the debriefer are stating exactly what you saw in the simulation and what you think about it, 2) more efficient because time isn’t being wasted as the learner tries to guess what it is you’re asking about, and 3) more likely to get to the learner’s cognitive frame efficiently. Here’s a hypothetical comparison. Let’s say the sim was about discharge teaching for a newly diagnosed diabetic:

Using GWIT Questions
“So, Sarah, what did you think of your communication?”

“I think it was OK… I mean, I tried to be sure that the patient got their treatment plan.”

“Sure, I agree… what about your other communication, not just with the patient?”

“Other communication? You mean the SBAR phone call? I thought I covered most of the bases. I could have given more background information on her medications, I guess….”

“No, no… what I’m trying to get at is the communication with the family….”

“Oh, the family! Well, I introduced myself and told them that I was going to be teaching their mom in preparation for discharge. They seemed OK with that… Is that what you mean?”

“Not exactly… Do you think that you used them as well as you could have, as part of the team that will be caring for the patient at home?”

“Well, I let them stay in the room, so they heard everything….”

“I thought that checking in with them to see if they understood everything and see if they had questions would have been a good thing to do. Did you think about that?”

“No… I get what you’re saying, I should have asked them.”

“OK, good.”

Elapsed time: 1minute, 19 seconds
Outcome: No learner frame revealed, though Sarah eventually did guess what the instructor was thinking.

Using Good Judgment Advocacy-Inquiries
“Sarah, I noticed that when you were doing discharge teaching you didn’t involve the family by checking with them to see if they understood or had questions. I think that they are going to be critical to the patient’s care at home and should be seen as part of the team. How were you seeing it?”

“Oh, I really didn’t think about that… I was so focused on the patient and checking her understanding that I didn’t really think about them… I don’t consider the family part of the care team. I had pictured the patient taking care of herself with periodic visits from a home health nurse. I guess there are going to be plenty of times that it’ll just be the patient and her family there, won’t there… It would really be helpful if they knew what to do, wouldn’t it?”

Elapsed time: 43 seconds
Outcome: We got her frame: she doesn’t think the family is part of the care team!

Speaking of video: using video can be a great resource, but it doesn’t get you off the hook for telling your learners what you saw in the video and telling them what you think about it! Otherwise, it’s just a GWIT with pictures.

-Mary Fey, Associate Director, Applied Learning for Performance and Safety

Resources:
The foundational DWGJ article is worth a read (or a re-read): Rudolph, J.W., Simon, R., Dufresne, R.L. and Raemer, D.B., 2006. There’s no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simulation in Healthcare, 1(1), pp. 49-55.

For a broader view of different approaches, this article is excellent: Sawyer, T., Eppich, W., Brett-Fleegler, M., Grant, V. and Cheng, A., 2016. More than one way to debrief: a critical review of healthcare simulation debriefing methods. Simulation in Healthcare, 11(3), pp. 209-217.