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Is distance debriefing the new normal?

Pier Luigi Ingrassia
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2020 Covid–19 changed the way we live and work indefinitely. Is distance debriefing still an alternative debriefing method or become a common and standard way to debrief learners and peers? Should educators place increased emphasis on specific strategies to conduct enthusiastic virtual dialog? The SIMZINE panel debates the pressing issues.


The debate

The COVID-19 pandemic has required a quick response to the unprecedented suspension of face-to-face education worldwide. As a consequence, it pushed remote simulation and online distance debriefings. We spent long days of screen time connecting with students and peers with the aim of creating meaningful learning. Now the world is apparently ‘returning to normal.’ Nevertheless, distance simulation will not disappear. Actually, it will be our future. In a recent survey, in fact, the great majority of respondents indicated they would not abandon virtual distance simulation.

They continue some form of online simulation. In this scenario, simulationists and educators should adapt their current debriefing approaches to online platforms. Or probably they have to develop new competences. What is required to create successful virtual debriefing environments? Undoubtedly, debriefing distant learners online introduces considerable challenges. Technical constraints strongly change the dynamics between learners and facilitators in virtual group settings. For example, computer interfaces interfere with non-verbal cues such as eye contact or facial expressions. Technical challenges, such as poor video transmission, may impact the quality of debriefing conversations. Technical difficulties, for instance, may distract from the relevant tasks of facilitating discussion. 

So what can we do?

Diego Andrés Díaz-Guio

Doctor and surgeon, specialist in intensive care medicine, fellowship in simulation, and PhD in Educational Sciences. Director of a clinical simulation center, and professor of Intensive care Medicine in Colombia. He is currently the president of the Latin American Federation of Clinical Simulation (FLASIC).

Janice C. Palaganas

Professor of Health Professions Education and Associate Chair of the Health Professions Education Department at MGH Institute of Health Professions. Lecturer at Harvard Medical School, and Principal Faculty for the Center for Medical Simulation. Editor of 3 textbooks, authored several chapters, seminal articles and field-changing research. Currently CEO of the Institute for Interprofessional Innovations and executive coach for hospital and academic leaders. Co-podcaster on “DJ Simulationistas….’sup?” and “SimFails.”

Juan-Manuel Fraga-Sastrías

Physician with Paramedic background involved in Health Care Education since the early 90’s. 
Master in Educational Leadership, Master of Emergency Management and Doctorate in Health Sciences. Actually working as CEO in Cancer Center Tec 100 in México, and owns the Company Asesores en Emergencias.
Main interest in education is the relation between education and clinical outcomes.

Expertise in the role of debriefer is essential for delivery of quality simulation programs. In-person simulation and distance simulation offer some similarities but also many differences. Which are, then, the competences a distance debriefer should have?

Diego Andrés Díaz-Guio: Carrying out a debriefing that allows the construction of knowledge is undoubtedly a challenge when it is carried out in person and, of course, when it is carried out remotely. The skills that those who conduct a non-face-to-face debriefing (distance debriefing) must have, are similar to those required for face-to-face debriefing: active listening, situational awareness, flexibility, and assertive communication. Nevertheless, the objectives of the previous skills may differ between both modalities. I mentioned active listening first, since we found in one of our studies on online-synchronized clinical simulation that the main limitation of this modality is precisely the poor quality of the audio, which is affected by the saturation produced when the participants speak at the same time, diminishing the clarity and quality of the information that was later used during the deconstruction of the case.

Now, situational awareness is a skill that any good debriefer must develop. The dependence on the quality of the internet is a factor that plays an important role. Sometimes during the simulation or during the debriefing the video freezes, meaning part of the action is lost. It is necessary to maintain full attention, manage the information with the associated debriefer and even with the participants in order to have a complete picture of everything that happened during the session. In addition, in the case of distance simulation we found that the timing of the simulated case can be greater due to the turns that the participants take when speaking, and the requests for redundant information to be repeated due to the quality of audio and video reception. This means the debriefer must adapt to this kind of situations. Finally, assertive communication is a necessity for online debriefing; direct, honest, and respectful communication is required (just as in face-to-face debriefing). Taking into account that there are factors that limit the ideal performance, it is possible that the participants have not understood something, have lost some of the information of the case, and consequently make wrong decisions. It is essential to determine the cause(s) of the performance gap from the early stages of the debriefing.

Juan-Manuel Fraga-Sastrías: Apart from the basic competences of face-to-face simulation such as communication skills, building relation, questioning techniques, etc., debriefers should now consider at least two new levels of complexity. Technical aspects: they need to be proficient in the use of teleconference software and be aware of other technical aspects to ensure a good debriefing experience for the participants. For example, building up redundancy with their internet connection and electricity. I do that by having an extra telephone plan that allows me to share the internet with my computer and have it charged in case there is a blackout where I am working. An alternative method of communication (such as a WhatsApp group) can be established in cases where there are technical difficulties and need to make a secondary adaptation (e.g. closing the meeting for an intrusion and opening an alternative session).

Method: although the normal phases of each debriefing are the same when doing it online, some etiquette (netiquette) rules should be shared and agreed with the participants. The debriefing can also be enriched with the use of whiteboards, emoticons, chat, etc. It is not that hard to provide with video-debriefing strategies, but for sure the debriefer should be more knowledgeable on how to select, share and discuss video scenes when doing an online-debriefing in which video from the scenario will have to be used. Also, some strategies to build up psychological safety and enhance the conversation should be considered. In most cases it takes longer between the simulation activity and the debriefing and it is also something to consider when beginning the debriefing.

Janice C. Palaganas: My PhD students in the simulation track at MGH IHP ran a delphi study to finalize Healthcare Distance Sim Educator Competencies in collaboration with the Society for Simulation in Healthcare and the Healthcare Distance Simulation Collaboration. That study has been submitted for publication. So I don’t want to be a spoiler 🙂 By the way, the background for that work may be found in the whitepaper titled The Creation of Healthcare Distance Simulation Educator Development Guidelines and published almost 9 months ago in September 2021. However, I would like to advise readers to adopt “lightly” the competencies published in this White Paper as they have since changed post the Delphi study.


Various techniques comprise the debriefing toolbox, such as advocacy inquiry, directive feedback, circular questions and many more. Based on your experience, are there conversational techniques which better apply to distance learning?

Juan-Manuel Fraga-Sastrías: I believe the more the merrier. In that sense all the communication competences are needed. The facilitator will need all of them and apply depending on specific situations (e.g., cameras closed, silent participants, problems with bandwidth, etc.). Nevertheless, the

debriefer can enhance communication by using “extra” tools such as the chat (encouraging participants to react also through the chat, sharing notes, coordinating questions with a co-debriefer, etc.), reactions (emoticons) as a way to substitute partially non-verbal communication,

and considering aspects as illumination, camera used, etc. to enhance the feeling of “contact” amongst participants and debriefer. Being conscious about aspects such as looking at the camera to make the participants feel there is eye contact, using their names to make them feel you are looking at them are aspects of digital communication that can enhance the conversation. Silences are also different, the debriefer needs to consider that when he/she makes a question the phrase will travel through the internet to the participants, then they think and answer, then the phrase will travel back through the internet… Although the transmission speed is fast, it takes a fraction of a second to a second for the phrases to travel through the internet. Longer silences are needed in that sense.

Janice C. Palaganas: Also soon to be submitted for publication is a conceptual model for distance debriefing that is quite robust as we conducted 5 separate studies to explore parts of the model. All conversational techniques work in web conferencing and the exploration of which has better outcomes would not be very different than in-person. This being said, there are many many other considerations in the online environment that the Healthcare Distance Simulation Collaboration has been feverishly researching. Our preliminary findings thus far are challenges and benefits that would be experienced by any conversational technique. A few of these studies also submitted for publication are: the impact of videos on/videos off, perspectives of debriefers vs debriefees, the use of emoji, nonverbals in the online environment, psychological safety and confidentiality, human factors, diversity and inclusivity, technology competencies.

Diego Andrés Díaz-Guio: In our case, we use the same methodology for both face-to-face and distance debriefing: we worry about allowing the expression of emotions before moving onto the cognitive stage. We have realized that more often people show their mental frameworks at this stage, which allows us to make a much simpler and much more fruitful inquiry – exploration.

Another aspect that has helped us is allowing the case to be reconstructed from the participants point of view, and not from the debriefers. Many times, the participants perceive elements that were not necessarily in the “script” of the case during crisis care (most of our simulations revolve around critically ill patients); getting to know the “reality” from the perception of the participants encourages and improves the flow of conversation.In sum, I think that

building trust based on an early explanation of the function and stages of debriefing, as well as the advantages and limitations that distance simulation and its debriefing have, favors trust, and trust notably favors dialogue.

Psychological safety is the perception amongst learners that they feel safe enough to take interpersonal risks without repercussions. Creating and maintaining psychological safety in a distance debriefing is also a key. What should we do to create it?

Janice C. Palaganas: Psychological safety is key to engagement in distance debriefing and the threat to psychological safety may be greater during web conferencing, e.g., Are participants in a private setting or are their colleagues listening? Are participants comfortable with their background? Are participants individually screen or audio recording? If the session is recorded, will it really be protected? There’s also the cognitive load of each individual worrying about how they appear on-screen (a finding in one of our studies).

Diego Andrés Díaz-Guio: As mentioned earlier, trust is the fundamental input for an efficient and constructive debriefing. I think that something that has helped us in the simulation center is to explain the intention of the debriefing, and the power that reflective, conscious, and intentional conversations have in simulation-based education processes. Our participants know from the introduction to the activity what debriefing means, with the intention that they can have a better cognitive engagement, but also, because we believe that it is important for them to learn to do debriefing in their real clinical practices with their teams, with the aim of building safer and more reliable medical teams. I believe that assertive communication is a fundamental piece to achieve learning conversations. If we as educators expose our thoughts in a respectful yet honest manner about what we want to talk about, it is very likely that the participants will trust and feel safe with us, thus, they will act in the same way.

Juan-Manuel Fraga-Sastrías: As in face-to-face debriefings, online-debriefings need ways to increase psychological safety. Break-the-ice exercises and introductions are needed (as in face-to-face debriefings) but can be enhanced with some digital tools. There is a huge number of digital activities that can be used to break-the-ice, get to know participants. Digital etiquette rules (netiquette) can be shared with the participants before the first connections, aspects such as: use of camera, microphones, video recording, meeting security (password, waiting room, etc.), active participation should be agreed with the participants. 

Recording of the session should only be used as a quality and supervision measure (for the debriefer) but not shared outside the group. Some level of flexibility and support is also needed, mainly with the first sessions.


Let’s not forget the economic aspect. Does distance simulation have the advantage of being cheaper?

Diego Andrés Díaz-Guio: In the economic aspect, I believe that distance simulation can be cheaper than face-to-face simulation for the participant. In the simulation center we still carry out non-face-to-face simulation, and this has allowed people from different parts of Latin America to participate in the simulations without incurring the expenses involved in traveling to our training simulation center, which is located in Colombia. What we’ve done so far is: we do the telesimulation from the simulation center, with the entire team of people and resources usually involved in the face-to-face simulation, and through platforms that offer good audio and video quality. Meanwhile, our participants join the session from Argentina, Mexico, Chile, and Peru all at the same time. Non-presential simulation is an activity that allows for: learning, skill development, and even evaluating the participants, all while reducing borders and lowering costs.

Janice C. Palaganas: In our Healthcare Distance Simulation Annual Summit this year, one work group discussed justice, equity, diversity, and inclusivity, and came to consensus that distance sim is privilege. We cannot forget that. While access is better globally today, it is still not equal, especially bandwidth and speed. I do not believe that distance simulation, if done right, will necessarily be less expensive.

I believe that it will increase access (especially in situations where recording or observation is allowed), but I believe that it will be another parallel arm of simulation programs with its own human and technology needs, as well as faculty and staff development.

As most institutions now have a goal for inclusivity, it will be important for programs to consider the lowest common denominator of access/ability that effectively meets the objectives of the education. For example, if VR is chosen, provision of devices to those who do not have them may be costly. Training of the devices will also need to be built in tech support and faculty training, etc.

Juan-Manuel Fraga-Sastrías: I believe that depending on the context, the costs might be higher or lower. It is hard to calculate the real costs of online debriefing since the internet connection, equipment and other resources’ costs are shared with the participants. Aspects in which cost might be higher: devices used to connect to the debriefing, cameras, microphones, internet connections, teleconference platform. Aspects in which cost is reduced: less use of physical space, transportation times, establishing logistics. In most cases the dispersed costs (internet, devices, etc) are related to resources that most of the participants would be expected to have for other educational, recreational and professional activities so I would expect a reduction in costs, but again as I said before, it depends a lot on the context.


Conclusion

Carrying out an effective debriefing is undoubtedly a challenge also when it is carried out remotely. Nevertheless debriefers should now consider new levels of complexity. Digital tools need to be used wisely and proficiently to prevent them from becoming a barrier. Distance simulation increases access and it will be another parallel arm of simulation programs with its own human and technology limitations, as well as faculty and staff development.


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Pier Luigi Ingrassia
Author

Pier Luigi Ingrassia

Centro di Simulazione (CeSi), Centro Professionale Sociosanitario Lugano View all Posts

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