Identifying best practice guidelines for debriefing in surgery: a tri-continental study

Ward-based in situ simulation: lessons learnt from a UK District General Hospital

INTRODUCTION

In situ simulation (ISS) enables multiprofessional healthcare teams to train for real emergencies in their own working environment and identify latent patient safety threats. This study aimed to determine ISS impact on teamwork, technical skill performance, healthcare staff perception and latent error identification during simulated medical emergencies.

MATERIALS AND METHODS

Unannounced ISS sessions (n=14, n=75 staff members) using a high-fidelity mannequin were conducted in medical, paediatric and rehabilitation wards at Stepping Hill Hospital (Stockport National Health Service Foundation Trust, UK). Each session encompassed a 15 min simulation followed by a 15 min faculty-led debrief.

RESULTS

The clinical team score revealed low overall teamwork performances during simulated medical emergencies (mean±SEM: 4.3±0.5). Linear regression analysis revealed that overall communication (r=0.9, p<0.001), decision-making (r=0.77, p<0.001) and overall situational awareness (r=0.73, p=0.003) were the strongest statistically significant predictors of overall teamwork performance. Neither the number of attending healthcare professionals, their professional background, age, gender, degree of clinical experience, level of resuscitation training or previous simulation experience statistically significantly impacted on overall teamwork performance. ISS positively impacted on healthcare staff confidence and clinical training. Identified safety threats included unknown location of intraosseous kits, poor/absent airway management, incomplete A-E assessments, inability to activate the major haemorrhage protocol, unknown location/dose of epinephrine for anaphylaxis management, delayed administration of epinephrine and delayed/absence of attachment of pads to the defibrillator as well as absence of accessing ALS algorithms, poor chest compressions and passive behaviour during simulated cardiac arrests.

CONCLUSION

Poor demonstration of technical/non-technical skills mandate regular ISS interventions for healthcare professionals of all levels. ISS positively impacts on staff confidence and training and drives identification of latent errors enabling improvements in workplace systems and resources.

'Herding cats': A mixed methods investigation into the educational value of debriefing in operating theatres

AIM

The aim of the study was to explore the value of debriefing to enhance learning within operating theatres.

METHODS

A sequential mixed method study was undertaken at a local District General Hospital Trust in 2020. A total of 106 surveys were distributed to all multidisciplinary team members based in the trauma and orthopaedic theatres. Following the survey stage, 11 in-depth semi-structured qualitative interviews were undertaken with volunteers from the survey stage which included a range of health care professionals.

FINDINGS

Participants identified debriefing as a valuable tool for learning and reflection. However, significant barriers were identified, including lack of time and conflicting priorities. Some interviewees referred to the current debriefing process as a 'tick box' and a 'herding cats' exercise, attributing it to a lack of structure, leadership and organisational buy-in.

CONCLUSIONS

Debriefing in the operating theatre is a valuable tool for individual and team learning. However, formalising the structure of the debriefing, along with joint team and organisational commitment, was deemed vital in optimising the value of debriefings in the future.

Helping healthcare teams to debrief effectively: associations of debriefers' actions and participants' reflections during team debriefings

BACKGROUND

Debriefings help teams learn quickly and treat patients safely. However, many clinicians and educators report to struggle with leading debriefings. Little empirical knowledge on optimal debriefing processes is available. The aim of the study was to evaluate the potential of specific types of debriefer communication to trigger participants' reflection in debriefings.

METHODS

In this prospective observational, microanalytic interaction analysis study, we observed clinicians while they participated in healthcare team debriefings following three high-risk anaesthetic scenarios during simulation-based team training. Using the video-recorded debriefings and INTERACT coding software, we applied timed, event-based coding with DE-CODE, a coding scheme for assessing debriefing interactions. We used lag sequential analysis to explore the relationship between what debriefers and participants said. We hypothesised that combining advocacy (ie, stating an observation followed by an opinion) with an open-ended question would be associated with participants' verbalisation of a mental model as a particular form of reflection.

RESULTS

The 50 debriefings with overall 114 participants had a mean duration of 49.35 min (SD=8.89 min) and included 18 486 behavioural transitions. We detected significant behavioural linkages from debriefers' observation to debriefers' opinion (z=9.85, p<0.001), from opinion to debriefers' open-ended question (z=9.52, p<0.001) and from open-ended question to participants' mental model (z=7.41, p<0.001), supporting our hypothesis. Furthermore, participants shared mental models after debriefers paraphrased their statements and asked specific questions but not after debriefers appreciated their actions without asking any follow-up questions. Participants also triggered reflection among themselves, particularly by sharing personal anecdotes.

CONCLUSION

When debriefers pair their observations and opinions with open-ended questions, paraphrase participants' statements and ask specific questions, they help participants reflect during debriefings.

Risky Decision Making Due to Goal Conflicts in Firefighting—Debriefing as a Countermeasure to Enhance Safety Behavior

Firefighters act within extreme environments, work under threatening conditions and are often exposed to goal conflicts (e.g., self-protection vs. mission objective) during their missions. However, what are the consequences of these safety and task goal conflicts, and what countermeasures could help to reduce their occurrence? In an online survey, 340 firefighters were asked about goal conflicts, risky decision making, debriefings and the frequency of difficulties in teamwork during firefighting. Associations between the survey variables were determined by multivariate regression and mediation analyses. Data show that goal conflicts were associated with risky decision making and unsafe acts. Furthermore, debriefings were associated with fewer goal conflicts, as mediated by less-frequent difficulties with teamwork (communication, leadership and shared mental models). Though limited by the cross-sectional design of our study, the results provide evidence that debriefing is a valuable tool to reduce difficulties experienced with teamwork on missions and therefore reduce the occurrence of conflicting goals. Fewer goal conflicts are associated with a decrease in unsafe decisions and, thus, a safer working environment for firefighters. Accordingly, it is recommended to conduct debriefings, with an increased focus on team aspects.

Improvement in student-led debriefing analysis after simulation-based team training using a revised teamwork assessment tool

BACKGROUND

Team debriefing is an important teamwork development intervention for improving team outputs in healthcare. Debriefing is a key component of experiential team training teamwork development interventions such as simulation-based training. Improving the quality of debriefing of healthcare teams, therefore, has multiple benefits. We investigated whether the quality of student-led debriefing improved using a shortened guide.

METHODS

Senior medical students, nurse anesthesia students, and senior undergraduate nursing students participated in student operating room team training at a health sciences center in the southeastern United States. Student teams participated in a dual-scenario simulation-based training session with immediate after-action debriefings after each scenario. In 2018, student teams conducted the second debriefing using as a guide the teamwork assessment scale, an 11-item, 3-subscale, 6-point Likert-type instrument. In 2019, they used a shortened, revised, 5-item version of the teamwork assessment scale, the quick teamwork assessment scale. Trained observers rated the quality of the student-led debriefings using the Objective Structured Assessment of Debriefing, an 8-item, 5-point instrument. The Wilcoxon-Mann-Whitney test was used to compare the teamwork assessment scale-guided and the quick teamwork assessment scale-guided mean item debriefing scores.

RESULTS

Two observers rated 3 student-led team debriefings using the teamwork assessment scales as a guide in 2018, and 6 such debriefings happened using the quick teamwork assessment scale as a guide in 2019. For each debriefing, observer scores were averaged for each Objective Structured Assessment of Debriefing item; these mean scores were then averaged with other mean scores for each year. The use of the quick teamwork assessment scale resulted in a statistically significant higher mean score for the Analysis Objective Structured Assessment of Debriefing item compared with the use of the teamwork assessment scale (4.92 [standard deviation 0.20] versus 3.83 [standard deviation 0.76], P = .023).

CONCLUSION

The use of a shortened teamwork assessment instrument as a debriefing guide for student teams in student operating room team training was more effective in analysis of actions than the original, longer tool. Next steps include determining the efficacy of the quick teamwork assessment scale in an actual clinical setting.

Learning in the Operating Theatre: A Thematic Analysis of Opportunities Lost and Found

OBJECTIVE

The operating theatre (OT) is an important learning environment. Trainees face barriers to learning in the OT that may reduce meaningful educational interactions. The impact of these barriers on the intraoperative learning experience of trainees and the strategies that they employ to overcome them are not known. This qualitative study aimed to describe the intraoperative learning experiences of senior general surgery trainees in Australia and their strategies to optimize learning in the OT.

DESIGN, SETTING, PARTICIPANTS

The authors developed a semi-structured interview guide based on published literature. Purposive sampling was used to identify a representative group of general surgery trainees in Australia, who were interviewed in a private setting with audio recordings deidentified for verbatim transcription and analysis. Thematic analysis was conducted using an interpretivist approach to produce a coding framework.

RESULTS

Ten trainees participated in the study. Themes were divided into external and internal barriers to learning, promoters of effective learning and actions to facilitate learning. External barriers included cultural neglect of an important issue, with inadequate prioritization of teaching and a lack of structure for intraoperative learning. From this, we identified the theme of missed opportunities. Internal barriers included difficulties in developing assertiveness required to address these issues and a failure to adequately plan for learning, with reliance on the mentor to initiate. Actions to facilitate learning were rarely employed by trainees, as most were unaware of strategies to maximize intraoperative learning.

CONCLUSIONS

Trainees find the barriers to learning in the OT difficult to address and are not well acquainted with strategies that may allow them to maximize their learning.

"A debriefer must be neutral" and other debriefing myths: a systemic inquiry-based qualitative study of taken-for-granted beliefs about clinical post-event debriefing

BACKGROUND

The goal of this study was to identify taken-for-granted beliefs and assumptions about use, costs, and facilitation of post-event debriefing. These myths prevent the ubiquitous uptake of post-event debriefing in clinical units, and therefore the identification of process, teamwork, and latent safety threats that lead to medical error. By naming these false barriers and assumptions, the authors believe that clinical event debriefing can be implemented more broadly.

METHODS

We interviewed an international sample of 37 clinicians, educators, scholars, researchers, and healthcare administrators from hospitals, universities, and healthcare organizations in Western Europe and the USA, who had a broad range of debriefing experience. We adopted a systemic-constructivist approach that aimed at exploring in-depth assumptions about debriefing beyond obvious constraints such as time and logistics and focused on interpersonal relationships within organizations. Using circular questions, we intended to uncover new and tacit knowledge about barriers and facilitators of regular clinical debriefings. All interviews were transcribed and analyzed following a comprehensive process of inductive open coding.

RESULTS

In total, 1508.62 min of interviews (25 h, 9 min, and 2 s) were analyzed, and 1591 answers were categorized. Many implicit debriefing theories reflected current scientific evidence, particularly with respect to debriefing value and topics, the complexity and difficulty of facilitation, the importance of structuring the debriefing and engaging in reflective practice to advance debriefing skills. We also identified four debriefing myths which may prevent post-event debriefing from being implemented in clinical units.

CONCLUSION

The debriefing myths include (1) debriefing only when disaster strikes, (2) debriefing is a luxury, (3) senior clinicians should determine debriefing content, and (4) debriefers must be neutral and nonjudgmental. These myths offer valuable insights into why current debriefing practices are ad hoc and not embedded into daily unit practices. They may help ignite a renewed momentum into the implementation of post-event debriefing in clinical settings.

Maximizing Learning in the Operating Room: Residents' Perspectives

BACKGROUND

Few studies examine how residents can optimize their educational experience in the OR on their terms. This study aimed to examine residents' perceptions of how learners can maximize their education in the OR.

METHOD

Using constructivist grounded theory methodology, the authors conducted focus groups with general surgery residents, PGY1-5, followed by semi-structured interviews with attending surgeons from a single, academic medical center. Constant comparison was used to identify themes and explore their relationships. Theoretical sampling was used until saturation was achieved.

RESULTS

Residents and attendings participated. Two phases of OR learning were identified, intra-operative and inter-operative. Characters that made optimized learning included control, struggling, and reflection. Residents who practiced self-reflection with their experiences, and were able to articulate this awareness to attendings, felt the OR was an ideal learning environment. Attendings echoed similar findings.

CONCLUSIONS

Providing residents with a method of maximizing OR learning is critical to postgraduate clinical education. Currently, observation passively morphs into active learning and eventually independent operating in the OR. However, residents who practice self-regulated learning, and are able to discuss their educational goals with attendings, seem to find the OR a better learning environment and progress to independence more quickly. This was echoed by practicing attendings. Providing residents with a generalizable, self-regulated learning framework specific to operative educational experiences could maximize learning potential and expedite resident progression in the OR.

Impact of Simulation-Based Training on Radiation Therapists' Workload, Situation Awareness, and Performance

Purpose

This study aimed to assess the impact of simulation-based training intervention on radiation therapy therapist (RTT) mental workload, situation awareness, and performance during routine quality assurance (QA) and treatment delivery tasks.

Methods and Materials

As part of a prospective institutional review board-approved study, 32 RTTs completed routine QA and treatment delivery tasks on clinical scenarios in a simulation laboratory. Participants, randomized to receive (n = 16) versus not receive (n = 16) simulation-based training had pre- and postintervention assessments of mental workload, situation awareness, and performance. We used linear regression models to compare the postassessment scores between the study groups while controlling for baseline scores. Mental workload was quantified subjectively using the NASA Task Load Index. Situation awareness was quantified subjectively using the situation awareness rating technique and objectively using the situation awareness global assessment technique. Performance was quantified based on procedural compliance (adherence to preset/standard QA timeout tasks) and error detection (detection and correction of embedded treatment planning errors).

Results

Simulation-based training intervention was associated with significant improvements in overall performance (P < .01), but had no significant impact on mental workload or subjective/objective quantifications of situation awareness.

Conclusions

Simulation-based training might be an effective tool to improve RTT performance of QA-related tasks.

Perceived Benefits of a Standardized Patient Simulation in Pre-Placement Dietetic Students

The purpose of this study was to evaluate the effect of a simulation-based learning (SBL) experience on perceived confidence in monitoring and evaluation, as part of the delivery of nutrition care of pre-placement dietetic students, and to describe their perceived value of the learning experience post-placement. A mixed method explanatory sequential study design was used. A confidence appraisal scale was developed and completed by students before (n = 37) and after (n = 33) a low fidelity simulation using a volunteer patient in an acute care setting. Two semi-structured focus group discussions with post-placement students (n = 17) were thematically analysed, grounded in phenomenology. Overall perceived confidence in monitoring and evaluating, as part of nutrition care, improved after the simulation [pre-SBL: 74 (62–83) vs. post-SBL: 89 (81–98.5), p = 0.00]. Two factors emerged to modulate confidence, namely (i) structure and (ii) authentic learning. Structure in turn was modulated by two key factors; safety and process. A low fidelity simulation using a standardised patient can improve students’ perceived confidence in monitoring and evaluation, and a well-structured authentic learning experience was valued and positively perceived by most dietetic students.

Okay, let's talk - short debriefings in the operating room

INTRODUCTION

Debriefing is increasingly used to enhance learning and reflection in clinical practice. Nevertheless, barriers to implementing debriefings in the operating room (OR) include lack of time, the availability of trained facilitators, and difficulty gathering the full team after surgery. Spending five minutes on a debriefing during skin closure or between procedures may enhance learning and reflection on practice, generating to improve patient safety. The aim of this study was to explore characteristics, feasibility and content of short debriefings in the OR.

METHODS

This was a mixed-method study of short debriefings, analyzing audio-recordings, field notes and relevance ratings from multi-professional teams, that conducted short debriefings in the OR at two University Hospitals in Denmark.

RESULTS

A total of 135 debriefings were conducted, with a median duration of five minutes (range 1:19 min-12:05 min). A total of 477 team members participated in the debriefings. The teams' median rating of relevance was 6 (range 1-10). The rating was higher following challenging events and in debriefings where the surgeon actively participated in the conversation. The teams discussed non-technical skills in all the debriefings and verbalized reflections on practice in 75 percent of the debriefings.

CONCLUSION

It was feasible to conduct short debriefings in a production-focused, complex work environment. In all the debriefings, the teams discussed various non-technical skills (NTS) and reflected on practice. The majority of team members rated the debriefings as relevant for their task management.

Modern Plastic Surgical Practice: Technical Competence Alone Is Not Enough

Annually, an estimated 234 million major surgical operations occur worldwide, with concomitant seven million complications and one million deaths. It is now well established that technical competence is necessary, but not sufficient for modern surgical practice and outcomes. Breakdown in non-technical skills has been attributed as a key root cause for near misses and patient harm in the operating room. This article discusses the multi-faceted skills-set that is necessary for the modern surgeon to succeed and for optimal patient outcomes. This includes technical skills, non-technical skills, with a focus on key CanMEDS framework domains, including leadership, communication, evidence-based surgery and mentorship.

Deliberate teaching tools for clinical teaching encounters: A critical scoping review and thematic analysis to establish definitional clarity

PURPOSE AND METHOD

We conducted a scoping review of tools designed to add structure to clinical teaching, with a thematic analysis to establish definitional clarity.

RESULTS

Six thousand and forty nine citations were screened, 434 reviewed for eligibility, and 230 identified as meeting study inclusion criteria. Eighty-nine names and 51 definitions were identified. Based on a post facto thematic analysis, we propose that these tools be named "deliberate teaching tools" (DTTs) and defined as "frameworks that enable clinicians to have a purposeful and considered approach to teaching encounters by incorporating elements identified with good teaching practice." We identified 46 DTTs in the literature, with 38 (82.6%) originally described for the medical setting. Forty justification articles consisted of 16 feedback surveys, 13 controlled trials, seven pre-post intervention studies with no control group, and four observation studies. Current evidence of efficacy is not entirely conclusive, and many studies contain methodology flaws. Forty-nine clarification articles comprised 12 systematic reviews and 37 narrative reviews. The most number of DTTs described by any review was four. A common design theme was identified in approximately three-quarters of DTTs.

CONCLUSIONS

Applicability of DTTs to specific alternate settings should be considered in context, and appropriately designed justification studies are warranted to demonstrate efficacy.

eAssessment: development of an electronic version of the Objective Structured Assessment of Debriefing tool to streamline evaluation of video recorded debriefings

Objective

The Objective Structured Assessment of Debriefing (OSAD) is an evidence-based, 8-item tool that uses a behaviorally anchored rating scale in paper-based form to evaluate the quality of debriefing in medical education. The objective of this project was twofold: 1) to create an easy-to-use electronic format of the OSAD (eOSAD) in order to streamline data entry; and 2) to pilot its use on videoed debriefings.

Materials and Methods

The eOSAD was developed in collaboration with the LSU Health New Orleans Epidemiology Data Center using SurveyGizmo (Widgix Software, LLC, Boulder, CO, USA) software. The eOSAD was then piloted by 2 trained evaluators who rated 37 videos of faculty teams conducting pre-briefing and debriefing after a high-fidelity trauma simulation. Inter-rater reliability was assessed, and evaluators' qualitative feedback was obtained.

Results

Inter-rater reliability was good [prebrief, intraclass correlation coefficient, ICC = 0.955 (95% CI, 0.912-0.977), P < .001; debrief, ICC = 0.853 (95% CI, 0.713-0.924), P < .001]. Qualitative feedback from evaluators found that the eOSAD was easy to complete, simple to read and add comments, and reliably stored data that were readily retrievable, enabling the smooth dissemination of information collected.

Discussion

The eOSAD features a secure login, sharable internet access link for distant evaluators, and the immediate exporting of data into a secure database for future analysis. It provided convenience for end-users, produced reliable assessments among independent evaluators, and eliminated multiple sources of possible data corruption.

Conclusion

The eOSAD tool format advances the post debriefing evaluation of videoed inter-professional team training in high-fidelity simulation.

A Novel Approach to Debriefing Medical Simulations: The Six Thinking Hats

Simulation has become a standard training method in emergency medicine (EM). Specifically, post-simulation debriefings offer participants the opportunity for reflection while exposing their knowledge and practice gaps. The educational yield of these debriefings, however, is contingent on the debriefer's skills. Without professional development, faculty and educators may not be equipped with supportive debriefing strategies. We propose the Six Thinking Hats (6TH), originally developed by Edward de Bono (1970) as a debriefing framework to support effective, high-yield debriefing conversations. The six colored hats represent six unique approaches to critical thinking. The white hat represents the facts; the green hat, creativity and next steps; the yellow hat, benefits/optimism; the red hat, emotions; the black hat, judgments; and the blue hat, facilitation. Four junior faculty members underwent a one-hour didactic and one-hour immersive workshop on the 6TH. Two simulation cases were randomly selected from archived simulation cases, which were used for the debriefing process. Each team consisted of one EM resident and one EM faculty. After each simulated case, the facilitator introduced the 6TH at the start of the debriefing, explaining the rules of engagement and the general sequence of hats to be used. Physical hats were worn by the facilitator at the beginning of the session and changed throughout stages of the debriefing, to remind participants of the type of thinking that was taking place at any given time. Participants who were provided with a colored hat prompt that physically described the type of thinking being employed throughout stages of the debriefing were better able to stay within that respective thinking frame during the discussion, compared to participants who were not provided this visual prompt. Participants of both simulation sessions agreed that the 6TH debriefing style was successful in creating a non-judgmental, comfortable environment that supported open discussion. The 6TH has the potential to be adopted as a debriefing framework, particularly for junior faculty members without extensive debriefing training. The 6TH is intuitive and has been marked by success in the organizational psychology literature. Faculty development on the 6TH will be essential if this framework is to be used as a debriefing model for educators in health care.

Promoting safety mindfulness: Recommendations for the design and use of simulation-based training in radiation therapy

There is a need to better prepare radiation therapy (RT) providers to safely operate within the health information technology (IT) sociotechnical system. Simulation-based training has been preemptively used to yield meaningful improvements during providers' interactions with health IT, including RT settings. Therefore, on the basis of the available literature and our experience, we propose principles for the effective design and use of simulated scenarios and describe a conceptual framework for a debriefing approach to foster successful training that is focused on safety mindfulness during RT professionals' interactions with health IT.

Trends in Research on Simulation in the Teaching of Nursing: An Integrative Review

AIM

The aim of the study was to identify and reflect on evidence regarding the use of simulation in nursing education.

BACKGROUND

The use of simulation as a teaching strategy in nursing is expanding. It is important to check the evidence deriving from research.

METHOD

Departing from a guiding question, an international literature search was undertaken between January 2008 and March 2014 in Portuguese, English, and Spanish.

RESULTS

Out of 160 articles, 68.1 percent used simulated teaching to develop clinical reasoning; 31.9 percent used it to train skills. Most (about 91.8 percent) discussed positive aspects related to the use of simulation, including support for the teaching process and increased self-efficacy and self-confidence.

CONCLUSION

The studies indicate that appropriate tools are needed to measure the true impact of the strategy on the teaching of nursing care and the training needed to use simulation as a teaching strategy.

Huddles and Debriefings: Improving Communication on Labor and Delivery

Interprofessional teams work together on the labor and delivery unit, where clinical care is often unscheduled, rapidly evolving, and fast paced. Effective communication is key for coordinated delivery of optimal care and for fostering a culture of community and safety in the workplace. The preoperative huddle allows for information sharing, cross-checking, and preparation before the start of surgery. Postoperative debriefings allow the operative team to engage in ongoing process improvement. Debriefings after adverse events allow for shared understanding, mutual healing, and help mitigating the harm to potential "second victims."

Perioperative feedback in surgical training: A systematic review

BACKGROUND

Changes in surgical training have raised concerns about residents' operative exposure and preparedness for independent practice. One way of addressing this concern is by optimizing teaching and feedback in the operating room (OR). The objective of this study was to perform a systematic review on perioperative teaching and feedback.

METHODS

A systematic literature search identified articles from 1994 to 2014 that addressed teaching, feedback, guidance, or debriefing in the perioperative period. Data was extracted according to ENTREQ guidelines, and a qualitative analysis was performed.

RESULTS

Thematic analysis of the 26 included studies identified four major topics. Observation of teaching behaviors in the OR described current teaching practices. Identification of effective teaching strategies analyzed teaching behaviors, differentiating positive and negative teaching strategies. Perceptions of teaching behaviors described resident and attending satisfaction with teaching in the OR. Finally models for delivering structured feedback cited examples of feedback strategies and measured their effectiveness.

CONCLUSIONS

This study provides an overview of perioperative teaching and feedback for surgical trainees and identifies a need for improved quality and quantity of structured feedback.

Characteristics of Real-Time, Non-Critical Incident Debriefing Practices in the Emergency Department

INTRODUCTION

Benefits of post-simulation debriefings as an educational and feedback tool have been widely accepted for nearly a decade. Real-time, non-critical incident debriefing is similar to post-simulation debriefing; however, data on its practice in academic emergency departments (ED), is limited. Although tools such as TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) suggest debriefing after complicated medical situations, they do not teach debriefing skills suited to this purpose. Anecdotal evidence suggests that real-time debriefings (or non-critical incident debriefings) do in fact occur in academic EDs;, however, limited research has been performed on this subject. The objective of this study was to characterize real-time, non-critical incident debriefing practices in emergency medicine (EM).

METHODS

We conducted this multicenter cross-sectional study of EM attendings and residents at four large, high-volume, academic EM residency programs in New York City. Questionnaire design was based on a Delphi panel and pilot testing with expert panel. We sought a convenience sample from a potential pool of approximately 300 physicians across the four sites with the goal of obtaining >100 responses. The survey was sent electronically to the four residency list-serves with a total of six monthly completion reminder emails. We collected all data electronically and anonymously using SurveyMonkey.com; the data were then entered into and analyzed with Microsoft Excel.

RESULTS

The data elucidate various characteristics of current real-time debriefing trends in EM, including its definition, perceived benefits and barriers, as well as the variety of formats of debriefings currently being conducted.

CONCLUSION

This survey regarding the practice of real-time, non-critical incident debriefings in four major academic EM programs within New York City sheds light on three major, pertinent points: 1) real-time, non-critical incident debriefing definitely occurs in academic emergency practice; 2) in general, real-time debriefing is perceived to be of some value with respect to education, systems and performance improvement; 3) although it is practiced by clinicians, most report no formal training in actual debriefing techniques. Further study is needed to clarify actual benefits of real-time/non-critical incident debriefing as well as details on potential pitfalls of this practice and recommendations for best practices for use.

Simulation With PARTS (Phase-Augmented Research and Training Scenarios): A Structure Facilitating Research and Assessment in Simulation

INTRODUCTION

Assessment in simulation is gaining importance, as are scenario design methods increasing opportunity for assessment. We present our approach to improving measurement in complex scenarios using PARTS [Phase-Augmented Research and Training Scenarios], essentially separating cases into clearly delineated phases.

METHODS

We created 7 PARTS with real-time rating instruments and tested these in 63 cases during 4 weeks of simulation. Reliability was tested by comparing real-time rating with postsimulation video-based rating using the same instrument. Validity was tested by comparing preintervention and postintervention total results, by examining the difference in improvement when focusing on the phase-specific results addressed by the intervention, and further explored by trying to demonstrate the discrete improvement expected from proficiency in the rare occurrence of leader inclusive behavior.

RESULTS

Intraclass correlations [3,1] between real-time and postsimulation ratings were 0.951 (95% confidence interval [CI], 0.794-0.990), 1.00 (95% CI, --to--), 0.948 (95% CI, 0.783-0.989), and 0.995 (95% CI, 0.977-0.999) for 3 phase-specific scores and total scenario score, respectively. Paired t tests of prelecture-postlecture performance showed an improvement of 14.26% (bias-corrected and accelerated bootstrap [BCa] 95% CI, 4.71-23.82; P = 0.009) for total performance but of 28.57% (BCa 95% CI, 13.84-43.30; P = 0.002) for performance in the respective phase. The correlation of total scenario performance with leader inclusiveness was not significant (rs = 0.228; BCa 95% CI. -0.082 to 0.520; P = 0.119) but significant for specific phase performance (rs = 0.392; BCa 95% CI, 0.118-0.632; P = 0.006).

CONCLUSIONS

The PARTS allowed for improved reliability and validity of measurements in complex scenarios.

Putting the MeaT into TeaM Training: Development, Delivery, and Evaluation of a Surgical Team-Training Workshop

BACKGROUND

Despite importance to patient care, team training is infrequently used in surgical education. To address this, a workshop was developed by the Association for Surgical Education Simulation Committee to teach team training using high-fidelity patient simulators and the American College of Surgeons-Association of Program Directors in Surgery team-training curriculum.

METHODS

Workshops were conducted at 3 national meetings. Participants completed preworkshop and postworkshop questionnaires to define experience, confidence in using simulation, intention to implement, as well as workshop content quality. The course consisted of (A) a didactic review of Preparation, Implementation, and Debriefing and (B) facilitated small group simulation sessions followed by debriefings.

RESULTS

Of 78 participants, 51 completed the workshops. Overall, 65% indicated that residents at their institutions used patient simulation, but only 33% used the American College of Surgeons-the Association of Program Directors in Surgery team-training modules. The workshop increased confidence to implement simulation team training (3.4 ± 1.3 vs 4.5 ± 0.9). Quality and importance were rated highly (5.4 ± 00.6, highest score = 6).

CONCLUSIONS

Preparation for simulation-based team training is possible in this workshop setting, although the effect on actual implementation remains to be determined.

Structuring feedback and debriefing to achieve mastery learning goals

Mastery learning is a powerful educational strategy in which learners gain knowledge and skills that are rigorously measured against predetermined mastery standards with different learners needing variable time to reach uniform outcomes. Central to mastery learning are repetitive deliberate practice and robust feedback that promote performance improvement. Traditional health care simulation involves a simulation exercise followed by a facilitated postevent debriefing in which learners discuss what went well and what they should do differently next time, usually without additional opportunities to apply the specific new knowledge. Mastery learning approaches enable learners to "try again" until they master the skill in question. Despite the growing body of health care simulation literature documenting the efficacy of mastery learning models, to date insufficient details have been reported on how to design and implement the feedback and debriefing components of deliberate-practice-based educational interventions. Using simulation-based training for adult and pediatric advanced life support as case studies, this article focuses on how to prepare learners for feedback and debriefing by establishing a supportive yet challenging learning environment; how to implement educational interventions that maximize opportunities for deliberate practice with feedback and reflection during debriefing; describing the role of within-event debriefing or "microdebriefing" (i.e., during a pause in the simulation scenario or during ongoing case management without interruption), as a strategy to promote performance improvement; and highlighting directions for future research in feedback and debriefing for mastery learning.

The positive impact of structured teaching in the operating room

BACKGROUND

A survey of obstetric and gynaecology trainees in Australia found the trainee's opinion of the consultants' teaching ability for laparoscopic procedures and procedures dealing with complications as 'poor' in 21.2% and 23.4% of responses, respectively (Aust NZ J Obstet Gynaecol 2009; 49: 84). Surgical caseload per trainee is falling for a variety of reasons. Strategies need to be adopted to enhance the surgical learning experience of trainees in the operating room.

AIMS

We describe the use of a structured encounter template to facilitate the teaching of surgery in the operating room and report the response of the trainees to this intervention.

METHODS

Trainees attached to a gynaecologic surgery unit all underwent surgical training using a set format based on the surgical encounter template, including briefing, goal setting and intra-operative teaching aims as well as debriefing. Data on the trainees' experience and perception of their learning experience were then collected and analysed as quantitative and qualitative data sets.

RESULTS

The trainees reported satisfaction with the use of a structured encounter template to facilitate the surgical teaching in the operating room. Some trainees had not received such clarity of feedback or the opportunity to complete a procedure independently prior to using the structured encounter template.

CONCLUSIONS

A structured surgical encounter template based on andragogy principles to focus consultant teaching in the operating room is highly acceptable to obstetric and gynaecology trainees in Australia. Allowing the trainee the opportunity to set objectives and receive feedback empowers the trainee and enhances their educational experience.

Surgeons' and trainees' perceived self-efficacy in operating theatre non-technical skills

BACKGROUND

An important factor that may influence an individual's performance is self-efficacy, a personal judgement of capability to perform a particular task successfully. This prospective study explored newly qualified surgeons' and surgical trainees' self-efficacy in non-technical skills compared with their non-technical skills performance in simulated scenarios.

METHODS

Participants undertook surgical scenarios challenging non-technical skills in two simulation sessions 6 weeks apart. Some participants attended a non-technical skills workshop between sessions. Participants completed pretraining and post-training surveys about their perceived self-efficacy in non-technical skills, which were analysed and compared with their performance in surgical scenarios in two simulation sessions. Change in performance between sessions was compared with any change in participants' perceived self-efficacy.

RESULTS

There were 40 participants in all, 17 of whom attended the non-technical skills workshop. There was no significant difference in participants' self-efficacy regarding non-technical skills from the pretraining to the post-training survey. However, there was a tendency for participants with the highest reported self-efficacy to adjust their score downwards after training and for participants with the lowest self-efficacy to adjust their score upwards. Although there was significant improvement in non-technical skills performance from the first to second simulation sessions, a correlation between participants' self-efficacy and performance in scenarios in any of the comparisons was not found.

CONCLUSION

The results suggest that new surgeons and surgical trainees have poor insight into their non-technical skills. Although it was not possible to correlate participants' self-belief in their abilities directly with their performance in a simulation, in general they became more critical in appraisal of their abilities as a result of the intervention.

Postresuscitation debriefing in the pediatric emergency department: a national needs assessment

Objectives:

The objectives of this study were to assess current postresuscitation debriefing (PRD) practices in Canadian pediatric emergency departments (EDs) and identify areas for improvement.

Methods:

A national needs assessment survey was conducted to collect information on current PRD practices and perspectives on debriefing practice in pediatric EDs. A questionnaire was distributed to ED nurses, fellows, and attending physicians at 10 pediatric tertiary care hospitals across Canada. Summary statistics are reported.

Results:

Data were analyzed from 183 participants (48.7% response rate). Although 88.8% of the participants believed that debriefing is an important process, 52.5% indicated that debriefing after real resuscitations occurs less than 25% of the time and 68.3% indicated that no expectation exists for PRD at their institution. Although 83.7% of participants believed that facilitators should have a specific skill set developed through formal training sessions, 63.4% had no previous training in debriefing. Seventy-two percent felt that medical and crisis resource management issues are dealt with adequately when PRD occurs, and 90.4% indicated that ED workload and time shortages are major barriers to effective debriefing. Most responded that a debriefing tool to guide facilitators might aid in multiple skills, such as creating realistic debriefing objectives and providing feedback with good judgment.

Conclusion:

PRD in Canadian pediatric EDs occurs infrequently, although most health care providers agreed on its importance and the need for skilled facilitators.

Comprehensive feedback on trainee surgeons' non-technical skills

OBJECTIVE

This study aimed to explore the content of conversations, feedback style, and perceived usefulness of feedback to trainee surgeons when conversations were stimulated by a tool for assessing surgeons' non-technical skills.

METHODS

Trainee surgeons and their supervisors used the Non-Technical Skills for Surgeons in Denmark tool to stimulate feedback conversations. Audio recordings of post-operation feedback conversations were collected. Trainees and supervisors provided questionnaire responses on the usefulness and comprehensiveness of the feedback. The feedback conversations were qualitatively analyzed for content and feedback style. Usefulness was investigated using a scale from 1 to 5 and written comments were qualitatively analyzed.

RESULTS

Six trainees and six supervisors participated in eight feedback conversations. Eighty questionnaires (response rate 83 percent) were collected from 13 trainees and 12 supervisors. Conversations lasted median eight (2-15) minutes. Supervisors used the elements and categories in the tool to structure the content of the conversations. Supervisors tended to talk about the trainees' actions and their own frames rather than attempting to understand the trainees' perceptions. Supervisors and trainees welcomed the feedback opportunity and agreed that the conversations were useful and comprehensive.

CONCLUSIONS

The content of the feedback conversations reflected the contents of the tool and the feedback was considered useful and comprehensive. However, supervisors talked primarily about their own frames, so in order for the feedback to reach its full potential, supervisors may benefit from training techniques to stimulate a deeper reflection among trainees.