Q: The interprofessional simulation program at our hospital has really grown recently and I often conduct debriefings with teams consisting of nurses, MDs, pharmacists, respiratory therapists, and others. I’m a nurse and work primarily with one ED physician in our simulation center. At times, I find myself a bit intimidated when I have to debrief a very senior physician, or last week, the nurse who heads the cardiovascular intensive care unit. I find myself secretly thinking, “What can I possibly tell them that they don’t already know?” It gets me off my game in debriefing and I need to figure out how to get over it. Can you help?

A: Here is the good news: You don’t have to tell them anything they don’t already know! Problem solved, the end.

But sincerely—this is not an uncommon situation, and two things come to mind. Number 1: the role of the debriefing facilitator, and Number 2: Bloom’s Taxonomy. Allow me to explain.

Why is the debriefing facilitator in the room? Is it to transmit content knowledge to the participants? No! That is not our value!

Our primary role is to facilitate learner self-reflection. The facilitator guides a discussion about the events of the simulation and asks reflective questions to surface those learner thought processes which led to the observed actions. Topics are generally chosen based on learning objectives and based on any emergent needs identified during the simulation or in the first phase of the debriefing. (In our model, that’s the “reactions” phase.) Ideally, the clinical events and context of the simulation will not be new to the team—the situation should be one where team members have some prior content knowledge. Here is where Bloom’s taxonomy comes in! Simulation is about learners’ ability to apply what they already know in a realistic context.

When things go awry in simulation, the debriefing facilitator’s response isn’t based on knowledge gaps (“Let me tell you what you don’t seem to know about responding quickly to postpartum hemorrhage,”) but rather about learner actions and application (“I noticed that it took almost 10 minutes to get the fluids started. I was thinking, ‘Get the fluids up first; then you can discuss other treatment plans while you’re doing fluid resuscitation… What was going on at that time for you?’”).

Now you’re getting at a more important issue: What prevented them from doing step 1 in response to hypovolemic shock? It probably wasn’t that they didn’t know to replace volume. It was more likely team dynamics, decision making processes, etc., and these factors are much more interesting than “knowing” that increasing intravascular volume will increase BP in this context!

Now to deal with the very real problem of debriefing those with more clinical expertise than you. I’ve found that the best way to deal with this elephant in the room is to use the best practice for all such elephants—acknowledge it, say how you see it, and say how it will be incorporated into the experience. If I’m going to be debriefing a neurosurgeon and I’m a 3rd year resident, I’d describe my role during the prebriefing and say something like, “Dr. Smith is here today, and we’re fortunate to have someone with her knowledge of neurosurgery in the group; Dr. Smith, I may ask you to help me out if any clinical questions about neurosurgery come up—I hope that’s okay with you.” Warning: This does not erase the need for the facilitator to do preparatory background reading on the topic at hand! One does not want to appear completely clueless.

-Mary Fey, Associate Director, CMS-ALPS

Resources:

Bloom’s taxonomy: http://www.edpsycinteractive.org/topics/cognition/bloom.html