As simulation continues to evolve new debriefing methodologies are born. Here, Dr Jack Pottle outlines the what, how, and why of self-debriefing.

Simulation Evolution

Simulation design and facilitation practices evolve as new evidence is found and new technologies emerge⁽¹⁾. Debriefing – a vital component to embed the learning from any simulation – has also evolved to accommodate the changing landscape of simulation. 

Recent changes in healthcare simulation delivery include the exponential use of virtual simulation⁽²⁾. This has been triggered by the COVID-19 pandemic and driven by underlying advantages of unlimited access, remote use, and individual participation^(3,4).

However, these same features that make virtual simulation beneficial underscore the need to consider debriefs that do not require face-to-face, synchronous presence⁽⁵⁾.

So what is self-debriefing?

Self-debriefing is used in circumstances when facilitator-led debriefs are unfeasible, such as individual virtual simulations. It can also be used to complement any virtual simulation, as virtual debriefing poses a number of challenges. These are outlined in detail in the excellent paper A practical guide to virtual debriefings: communities of inquiry perspective^(6). 

Self-debriefing is not new – a form is incorporated into the 2015 paper Debriefing for Meaningful Learning⁽⁷⁾ – and a number of new papers have shed further light on best practices. 

Does self-debriefing work?

MacKenna et al. recently researched the topic extensively⁽⁵⁾ – performing an integrative literature review, screening 1,375 papers with 10 meeting inclusion criteria.

Of note, the papers covered multiple geographies, disciplines and simulation modalities. Origins of the research included Canada, the United States, China and Taiwan. Participants included undergraduate nursing students, medical school residents, anesthesia residents, emergency medical technicians, and neonatal intensive care clinicians. Types of simulation covered traditional and virtual simulation.

Despite varied methodologies and results across the ten included studies, the combined findings confirmed the equivalency of self-debrief with facilitator-led debrief.

“Well-designed self-debriefing provides equivalent outcomes to instructor-led debriefing”

MacKenna et al (2021)

Learners in both live and virtual simulations achieve similar gains in knowledge^(8,9), self-efficacy^(8,10), or later performance^(10,11,12).

This breadth of success across multiple modalities is hugely important, but should not be taken as a sign that we can leave the debrief to the learners. Rather, it needs to be carefully planned as part of the overall learning process.

What are the components of self-debriefing?

As with the multiple models of in-person debriefing, there are many ways of encouraging self-debrief. The key components of successful self-debriefing are to deliver feedback and encourage reflection. Feedback on performance can be provided in two main ways: self-assessment or automated assessment. 

Self-assessment usually involves a video review – the learner watches the simulation and compares their performance in it to their existing knowledge to determine correct and incorrect actions. Whilst this may work well for advanced learners, such as the graduate-level students⁽¹¹⁾, it seems to not be the best choice for less-experienced learners as it relies on learners having enough prior knowledge and maturity to critique themselves⁽⁵⁾.

Automated assessment, such as those provided by virtual simulation platforms, can provide immediate, standardized, objective feedback following a scenario. This independent assessment of performance can be used both by advanced and junior learners. It is also appropriate for those who have difficulty critiquing themselves objectively, and as such is a more widely applicable form of feedback provision, where the capability allows.

Having learners respond to questions serves to support self-reflection, which is a necessary component of debriefing⁽¹³⁾. There are numerous methods to encourage self-reflection, which largely correlate with the standard debriefing models, including PEARLS, plus Delta and many others.

The modality of self-reflection can either be spoken – which is quick and natural – or written. Whilst being slower, written reflection serves to provide an ongoing record of the learning journey and may serve to deepen reflection and enhance learning⁽¹⁴⁾. 

There is therefore a place for both of these modalities depending on the setting, and they do not need to be mutually exclusive.

What are the advantages of self-debriefing?

In addition to savings in resources and reduced need for instructors for facilitation, there are other advantages to self-debriefing.

Learners who debrief themselves describe having time to think, feeling less pressure to respond right away, and having privacy

Verkuyl et al. (2018) 

Risk-taking for learners, such as making a wrong choice or answering a question incorrectly, is removed during a self-debrief. This may be particularly beneficial for junior or less confident learners. 

This relates to psychological safety – the perceived consequence of taking a risk in front of others⁽¹⁵⁾ – which is essential in simulation and debriefing design⁽¹⁶⁾. 

What are the disadvantages of self-debriefing?

Though demonstrated to be effective, the capacity for promoting active reflection, even in well-designed self-debriefing exercises, remains unknown. Also, although just as effective, learner perception of self-debriefing is frequently lower relative to instructor-led debriefing⁽⁵⁾. This suggests room for improvement in self-debriefing design considerations, including clear guidance, appropriate feedback, and adequate support for self-reflection.

Can I combine forms of debrief?

Yes! There is no reason why the use of self-debrief and facilitator-led debrief should be exclusive. Learners can initially participate in a self-debrief, where there is privacy and ample time to reflect, then join up with a group for a facilitated debrief afterwards. By offering a group session asynchronously, students with unresolved questions may receive answers from educators and peers, and shared learning can occur^(8,14).

Of note, when two debriefing formats are combined and use the same questions or a similar set, students are more prepared for the second debrief because they have already worked through the debriefing questions in an individual and authentic manner⁽⁹⁾. 

Verkuyl notes profound benefits to combining debrief formats. For example, learners gain a deeper understanding of self in relation to others, and more thorough attention is given to the debrief questions. However, and perhaps most importantly, when the formats are used sequentially, the self debrief helps students solidify their decisions before entering in a group debrief. Subsequently, they are able to focus on considering others’ perceptions in the context of their own during the group debrief⁽⁹⁾. 

The quality of the  discussion in the group debrief also benefits from combined formats. For example, students’ authentic responses to the self-debrief questions can be a rich source of data to be shared in a group debrief. When students believed the self-debriefs were being read by their professors, they admitted to spending more time completing them⁽⁹⁾.

When to combine forms of debrief?

A challenge for educators is determining if the self-debrief is sufficient, or if and when students require further debriefing strategies like a facilitated small- or large-group debrief. 

When making this decision, educators need to consider students’ ability to reflect, the type of simulation, and the simulation content. For example, novice learners may need more facilitated and group debriefing experiences than the experienced learners. In addition, simulations dealing with sensitive or emotional content may require a more facilitated, immediate debrief⁽⁹⁾.

Summary

Self-debrief is an effective way of providing debrief after a simulation, and equivalent to facilitator-led simulation in multiple contexts. The key components to self-debrief are the provision of feedback and the ability to encourage self-reflection. Self-reflection is improved by providing standardized feedback – particularly for more junior learners – and combining self-debrief with facilitator-led debrief may be the most effective strategy.

Dr. Jack Pottle
BSc, BMBCh, MRCP

Jack is a medical doctor, simulationist, and founder and chief medical officer of Oxford Medical Simulation