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J. Rudolph, R. Simon, Ronald Dufresne, D. Raemer (2006)There's No Such Thing as “Nonjudgmental” Debriefing: A Theory and Method for Debriefing with Good Judgment
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 1
(1984)The Consultation : an approach to learning and teaching
D. Brown, Gordon Ewy, Loryn Feinberg, J. Felner, I. Gessner, D. Gordon, Barry Issenberg, W. McGaghie, Rosanna Millos, E. Petrusa, Stewart Pringle, Ross Scalese, S. Small, R. Waugh, A. Ziv (2005)Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review
Medical Teacher, 27
R. Fanning, D. Gaba (2007)The Role of Debriefing in Simulation-Based Learning
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 2
Barbara Steinwachs (1992)How to Facilitate a Debriefing
Simulation & Gaming, 23
D. Raemer, Mindi Anderson, A. Cheng, R. Fanning, V. Nadkarni, G. Savoldelli (2011)Research Regarding Debriefing as Part of the Learning Process
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 6
P. Dieckmann, Susanne Friis, A. Lippert, D. Østergaard (2009)The art and science of debriefing in simulation: Ideal and practice
Medical Teacher, 31
W. McGaghie, S. Issenberg, E. Petrusa, Ross Scalese (2010)A critical review of simulation‐based medical education research: 2003–2009
Medical Education, 44
Corresponding author ' s contact details: Dr Peter Jaye, Director of SaIL Centres, Guy ' s and St Thomas' NHS Foundation Trust, Simulation and Interactive Learning (SaIL) Centre, 1 st Floor
James Robertson, K. Bandali (2008)Bridging the gap: Enhancing interprofessional education using simulation
Journal of Interprofessional Care, 22
R. Dismukes, D. Gaba, S. Howard (2006)So many roads: facilitated debriefing in healthcare.
Simulation in healthcare : journal of the Society for Simulation in Healthcare, 1 1
Feedback ‘The Diamond’: a structure for simulation debrief 1 1 2 Peter Jaye , Libby Thomas and Gabriel Reedy Simulation and Interactive Learning Centre (SaIL) , Guy s and St Thomas’ NHS Foundation Trust , London , UK King ’ s Learning Institute , King ’ s College London , UK SUMMARY through teaching simulation approach to high- quality debrief- Debrieﬁ ng is Background : Despite debrieﬁ ng debrieﬁ ng to hundreds of faculty ing on non- technical skills. the most being found to be the most members over several years. The Feedback from learners and from important important element in providing diamond shape visually repre- debrieﬁ ng faculty members has element in effective learning in simulation- sents the idealised process of a indicated that the Diamond is providing based medical education reviews, debrief: opening out a facilitated useful and valuable as a debrief- there are only a few examples in discussion about the scenario, ing tool, beneﬁ ting both partici- effective the literature to help guide a before bringing the learning back pants and faculty members. It learning in debriefer. The diamond debrieﬁ ng into sharp focus with speciﬁ c can be used by junior and senior simulation- method is based on the technique learning points. faculty members debrieﬁ ng in based medical of description, analysis and Innovation : The Diamond is a pairs, allowing the junior faculty education application, along with aspects of two- sided prompt sheet: the ﬁ rst member to conduct the descrip- the advocacy-inquiry approach and contains the scaffolding, with a tion phase, while the more reviews of debrieﬁ ng with good judgement . series of speciﬁ cally constructed experienced faculty member It is speciﬁ cally designed to allow questions for each phase of the leads the later and more chal- an exploration of the non- technical debrief; the second lays out the lenging phases. The Diamond aspects of a simulated scenario. theory behind the questions and gives an easy but pedagogically Context : The debrief diamond, a the process. sound structure to follow and structured visual reminder of the Implication : The Diamond speciﬁ c prompts to use in the debrief process, was developed encourages a standardised moment. © 2015 The Authors. The Clinical Teacher published by Association for the Study of Medical Education and John Wiley & Sons Ltd. 1171 71 THE CLINICAL TEACHER 2015; 12: 171–175 ttct_12300.indd 171 ct_12300.indd 171 5 5/14/2015 11:48:24 AM /14/2015 11:48:24 AM There are only a INTRODUCTION few examples in igh- ﬁ delity simulation uses the literature life- size manikins in actual to help guide a Hor recreated clinical debriefer environments to provide a clinical training experience without posing any risk to real patients. It can be used for all types of health care professional at any stage, pre- or post- qualiﬁ cation. Although it is used for many types of training, it is ideally suited for the teaching of non- technical skills such as teamworking, prioritising and leadership, and it provides a unique opportunity for inter- professional education. Simulation- based medical education reviews consistently ﬁ nd debrieﬁ ng to be the most important element in providing 2,3 effective learning. A commonly used deﬁ nition of debrieﬁ ng is a ‘facilitated or guided reﬂ ection in episodes of the authors, our decrease in didactic teaching. the cycle of experiential learning’ work training over 500 novices Candidates talked more and that occurs after a learning on courses and in practice by shared more clinical stories that event. Despite the recognised ‘debrieﬁ ng the debrief’. These illustrated non-technical skills importance of debrieﬁ ng, there experiences suggested that a (NTS) ; however, facilitators were are only a few examples in the structured visual reminder would still rarely able to develop literature to help guide a 5,6,7 beneﬁ t faculty members and speciﬁ c, personalised learning debriefer. Leading experts in participants. points for learners to take away. the ﬁ eld have called for work to ‘deﬁ ne explicit models of debrief- We observed that faculty Recognising these issues, we ing’. In response to this, the members often start a debrief believed the debrief sheet needed authors set out to develop a clear conﬁ dently, but can ﬁ nd it further evolution. This was when and simple visual aid to debrief- difﬁ cult to structure a discussion two ideas intersected. ing of clinical events, be they around non- technical skills. They simulated or real. 1 . Integrating a cognitive frequently allowed technical skills scaffold of question prompts to dominate the discussion, used The debrieﬁ ng method upon separated by clearly signpost- closed questions and reverted to which diamond is based has at its ed transitions between phases. didactic instructional approaches core the technique of description, or traditional feedback tools, 2 . Using the diamond shape to analysis and application, along such as Pendleton ’ s rules. visually represent the idealised with aspects of the advocacy- process of a debrief: opening inquiry approach and of debrief- We developed an initial out a facilitated discussion ing with good judgement. debrieﬁ ng aid for new simulation about the scenario, before faculty that listed speciﬁ c bringing the learning back CONTEXT questions, prompts, and remind- into sharp focus with speciﬁ c ers used in the description, learning points. The debrief diamond was devel- analysis, and application debrief- oped through the work of the ing model. This was integrated authors at the simulation centre INNOVATION into our faculty member debrief- of a large academic health ing courses and used during all of The Diamond was developed sciences centre and hospital our simulation courses. We as a double- sided page (see system in the UK. The Diamond observed an increase in the Figures 1 and 2). The ﬁ rst side was developed over time based quality of facilitation and a contains the scaffold, with a on the personal debrieﬁ ng 172 © 2015 The Authors. The Clinical Teacher published by Association for the Study of Medical Education and John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 171–175 ttct_12300.indd 172 ct_12300.indd 172 5 5/14/2015 11:48:26 AM /14/2015 11:48:26 AM series of speciﬁ cally constructed It enables questions for each phase of new faculty the description, analysis and members to application debrief. The second practise their side lays out the theory behind the questions and the process debrieﬁ ng enabling the debrieﬁ ng fac- skills ulty member to quickly remind themselves of the learning environment that they are trying to create, and how this can be achieved. Although the question prompts may seem didactic and inﬂ exible, this is purposeful, and suits the aim of a cognitive scaffold. It enables new faculty members to found that retaining the speciﬁ c Description practise their debrieﬁ ng skills, components, such as transitions The description process in- initially with close adherence to (e.g. ‘this scenario was designed volves taking the group through the prompts. When the faculty to show…’), serves to signpost an ‘agreed description’ of the member is more experienced, the the process for both learners and scenario that has just ﬁ nished. model can act as a guide rather faculty members, and thus This should be performed than a script. Faculty members improves the quality of the action- by- action, restricting the experienced in debrieﬁ ng have debrief. discussion to facts and avoiding emotion. The facilitator should start the debrief with a simple Debrief Diamond: Key Phrases to Remember non- judgmental phrase, and then direct the conversation to those candidates not involved in the scenario to engage them in the process. This allows the scenario participants to rest and to reﬂ ect on their colleagues’ recollections of the events, before giving their own accounts. We argue that it is vital that the facilitator acknowledges comments about the perceived quality of the performance, but redirects away from performance evaluation at this stage; the focus should remain on creating a shared understanding of what actually occurred in the scenario. This ensures that scenario participants do not feel under attack, and that a safe learning environment is maintained. Interestingly, we do not use a venting ‘How do you feel?’ question initially, as suggested by Rudolph et al. We have not found this necessary, and postulate that this may be cultural, in that the model was developed in a UK rather than in Figure 1 . The ﬁ rst side of the Diamond contains the scaffold with a series of speciﬁ cally constructed a US setting. questions for each phase of the description, analysis and application debrief © 2015 The Authors. The Clinical Teacher published by Association for the Study of Medical Education and John Wiley & Sons Ltd. 173 THE CLINICAL TEACHER 2015; 12: 171–175 ttct_12300.indd 173 ct_12300.indd 173 5 5/14/2015 11:48:28 AM /14/2015 11:48:28 AM The analysis phase is where At the end of the facilitator structures the the descriptive debrief around non- technical phase, the skills. Our faculty training facilitators can recommends that only one skill is clarify any explored in each debrief, to avoid cognitive overload for the outstanding learner. We encourage facilitators clinical issues to focus on the skill that the or technical learners – not the faculty questions members – feel was most relevant within the scenario. Faculty members can then construct a framework within which these skills can be examined and developed, using as a basis the shared and agreed experience of the scenario and the clinical experience of all participants. Once these are aired, the facilitator should illustrate positive (and, we argue, only very carefully, and with extreme caution, negative) examples of the non- technical skill that is to be the focus. Guiding the conversation, the faculty member can help to break this skill or behaviour down into speciﬁ c actions that participants can use in their clinical environments. This is a facilitative process, Figure 2 . The second side of the Diamond lays out the theory behind the questions and the debrief- during which the faculty member ing process reﬂ ects and summarises the suggestions of the group, At the end of the descriptive issues to prevent them from reframing them in non- technical phase, the facilitators can clarify dominating the analysis phase. language, as appropriate. any outstanding clinical issues or technical questions. The Diamond Analysis The facilitator next moves offers faculty members the The analysis phase starts with through the transition with the prompt ‘This scenario was an open question, such as ‘how phrase ‘So what we have talked designed to show…the recom- did you feel?’, directed to the about in this scenario is… What mended management of which scenario participants. It is impor- have we agreed that we could is…’ This phrase allows the tant that faculty members allow do?’ This reinforces the learning faculty members to clarify the enough time for the candidates about the NTS, ensuring a greater intentions of running the to compose their answer, even if likelihood of remembering the scenario, but accepts the a few moments of silence seems detail in clinical practice limitations and emergent nature uncomfortable. It may be neces- settings. of simulation as a learning sary to follow up the response setting. Summarising the clinical with ‘why?’, or similar prompts, Application management reinforces appropri- which can be asked multiple This phase encourages par- ate clinical knowledge, skills, times until underlying feelings ticipants to consider how they protocol adherence or behaviour, and motivations are revealed. may apply the knowledge in and addresses potential miscon- This cycle can be reﬂ ected back their own clinical practice. This ceptions without speciﬁ cally to the group to compare and aspect can be the most challeng- focusing on the performance of contrast perceptions and feel- ing for faculty members, as the participants. It also lessens the ings, and to explore the nature learning needs to be drawn to opportunity for collusion, and of any potential dissonance a conclusion in a very focused draws a line under the clinical expressed. way, without the introduction of 174 © 2015 The Authors. The Clinical Teacher published by Association for the Study of Medical Education and John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 171–175 ttct_12300.indd 174 ct_12300.indd 174 5 5/14/2015 11:48:29 AM /14/2015 11:48:29 AM alternative suggestions. Faculty design- based inquiry exploring Debrieﬁ ng sional education using simulation . members should ask for speciﬁ c how the intentions of the design J Interprof Care 2008 ; 22 : 499 – 508 . facilitators summary points from the par- are being reﬂ ected in actual 2 . Issenberg SB , McGaghie WC , need both ticipants who made particular debriefs, and in- depth interaction Petrusa ER , Lee Gordon D, speciﬁ c suggestions about non- technical and conversational analysis of Scalese RJ. Features and uses of high- ﬁ delity medical simulations skills and behaviours during the video recordings of diamond- techniques that lead to effective learning: a analysis phase. It is important based debriefs, which will and a clear BEME systematic review. Med Teach to allow one or two participants demonstrate the extent to which 2005 ; 27 : 10 – 28 . structure to to contextualise this skill within diamond- based debriefs show optimise 3 . McGaghie WC , Issenberg SB , Petrusa their own working environment. clear evidence of learning and ER , Scalese RJ . A critical review of learning during This emphasis on applying the engagement with the simulation simulation- based medical education new skills to their own environ- experience. a debrief research: 2003–2009 . Med Educ ments ﬁ nishes up the debrief in a 2010 ; 44 : 50 – 63 . focused, yet personalised, way. The feedback received from 4 . Fanning RM , Gaba DM . The Role debriefs of over 6000 learners in of Debrieﬁ ng in Simulation- Based Learning . Simul Healthc our centre, and from other allied IMPLICATIONS 2007 ; 2 : 115 – 125 . centres, shows that the Diamond Based on experiences in our encourages a standardised 5 . Steinwachs B . How to Facilitate a Debrieﬁ ng . Simulation Gaming centre, we argue that debrieﬁ ng approach to high- quality debrief- 1992 ; 23 : 186 – 195 . facilitators need both speciﬁ c ing across courses and institu- 6 . Rudolph JW , Simon R , Dufresne RL , techniques and a clear structure tions, beneﬁ ting both participants Raemer DB . There ’ s No Such Thing to optimise learning during a and faculty members. It facili- as ‘Nonjudgmental’ Debrieﬁ ng: A debrief. We have developed the tates debrieﬁ ng in pairs, as the Theory and Method for Debrieﬁ ng Diamond to address this need. transition phases are a perfect with Good Judgment. Simul Healthc Currently there is considerable point to switch faculty member; it 2006 ; 1 : 49 – 55 . variation between the perceived also allows junior faculty mem- 7 . Dieckmann P , Molin Friis S, ideal role of the debrief facilita- bers to conduct the relatively Lippert A, Østergaard D. The art tor and what is actually executed unproblematic description phase and science of debrieﬁ ng in simula- tion: Ideal and practice. Med Teach during real debrieﬁ ng sessions. while more experienced faculty 2009 ; 31 : e287 – e294 . We argue that a tool such as the members lead the later and more 8 . Raemer D , Anderson M , Cheng A , Diamond could help address this challenging phases. Fanning R , Nadkarni V , Savoldelli gap. G . Research regarding debrieﬁ ng as As a cognitive scaffold for part of the learning process . Simul Further research is currently in novice facilitators, we suggest Healthc 2011 ; 6 : S52 – S57 . process to deﬁ ne the extent to that the Diamond gives an easy 9 . Pendleton D , Schoﬁ eld T , Tate P , which this model does indeed and pedagogically sound struc- Havelock P . The consultation: an assist faculty members with the ture to follow, with speciﬁ c approach to learning and teaching . delivery of the post- simulation prompts to use in the moment. Oxford : Oxford University Press ; 1984 . debrief, and to what extent it enhances the learning of partici- REFERENCES 10 . Dismukes RK , Gaba DM , Howard SK . So Many Roads: Facilitated pants. This includes research 1 . Robertson J , Bandali K . Bridging Debrieﬁ ng in Healthcare. Simul validating the use of the Diamond the gap: Enhancing interprofes- Healthc 2006 ; 1 : 23 – 25 . in other settings, a more rigorous Corresponding author ’ s contact details: Dr Peter Jaye, Director of SaIL Centres, Guy ’ s and St Thomas’ NHS Foundation Trust, Simulation st and Interactive Learning (SaIL) Centre, 1 Floor, St Thomas House, St Thomas Hospital, Westminster Bridge Road, London, SE1 7EH, UK. E-mail: Peter.Jaye@gstt.nhs.uk Funding: Funding for the faculty development courses was mainly from the London Deanery STELI Project – Simulation and Technolgy Enhanced Learning Initiative. Conﬂ ict of interest: None. Acknowledgements: None. Ethical approval: Speciﬁ c ethical approval was not required for this project. The SaIL Centres have blanket ethical approval from its local ethics board for continuing educational research. No patients were involved in this research at any point. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. doi: 10.1111/tct.12300 © 2015 The Authors. The Clinical Teacher published by Association for the Study of Medical Education and John Wiley & Sons Ltd. 175 THE CLINICAL TEACHER 2015; 12: 171–175 ttct_12300.indd 175 ct_12300.indd 175 5 5/14/2015 11:48:30 AM /14/2015 11:48:30 AM
The Clinical Teacher – Pubmed Central
Published: May 25, 2015
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