Simulcast Journal Club March 2020 – Conceptual Framework for Development of Debriefing Skills


Introduction :  

Simulcast Journal Club is a monthly series that aims to encourage simulation educators to explore and learn from publications on Healthcare Simulation Education.  Each month we publish a case and link a paper with associated questions for discussion.  Inspired by the ALiEM MEdIC series, we moderate and summarise the discussion at the end of the month, including exploring the opinions of experts from the field. 

The journal club relies heavily on your participation and comments and while it can be confronting to post your opinions on an article online, we hope we can generate a sense of “online psychological safety” enough to empower you to post!  Your thoughts are highly valued and appreciated, however in depth or whatever your level of experience.  We look forward to hearing from you. 

Title :  “Learning to Fly 

The Case :  

Annika watched in admiration as her mentor completed a masterful multidisciplinary debrief.  Despite a pretty large crowd, William somehow managed to create a sense of intimacy that generated an enthralling and occasionally game changing conversation.  She hungered for that skillset. 

Clutching her PEARLS debriefing tool, she worked hard to break down why the conversation had been so effective, but while she found it helpful to structure her own debriefs with it, William seemed to dance about a through an array of different techniques in a way that made it hard to deconstruct afterward.  One minute he was utilising advocacy and inquiry, the next he essentially paused the discussion while facilitating an ‘expert in the room’ micro-tutorial on ventilation strategies.  It felt a bit like playing conversational strategy bingo, except that somehow when William did it, it all hung together comfortably. 

Annika had assumed that comprehensively understanding her traditional debrief phases would give her a sense of mastery in the learning conversation, but as she watched William in action it occurred to her that maybe it wasn’t being brilliant at one technique that made you an expert. 

The Article : 

Cheng, A., Eppich, W., Kolbe, M., Meguerdichian, M., Bajaj, K. and Grant, V. (2020). A Conceptual Framework for the Development of Debriefing Skills. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 15(1), pp.55-60. 

Discussion :  

When we learn about debriefing we are often taught a particular structure or conversational style that is seen to be essential to the technique.  In this month’s journal club article, Cheng et al propose a conceptual framework for development of debriefing skills, evoking the importance of adaptive expertise : the ability of a facilitator to change strategy or adapt technique on the fly to a specific situation or educational need. 

By mapping out the phases of ‘discovery, growth and maturity’, they outline stages of expertise within debriefing, but in doing so, they also challenge the notion that there is one way to debrief well,  opening us to the opportunities available to us to extend ourselves in different directions with debriefing. 

For this month we’d love to know what you think of the article, if you have any critique for the paper, and what thoughts this stimulates in your own practice regarding how you debrief, and how you cultivate growth in your colleagues. 

References : 

Cheng, A., Eppich, W., Kolbe, M., Meguerdichian, M., Bajaj, K. and Grant, V. (2020). A Conceptual Framework for the Development of Debriefing Skills. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 15(1), pp.55-60. 


About Ben Symon

Ben is a Paediatric Emergency Physician at The Prince Charles Hospital in Brisbane and a Simulation Educator at Lady Cilento Children's Hospital. He currently teaches on a variety of paediatric simulation based courses on paediatric resuscitation, trauma and CRM principles. Ben has a growing interest in encouraging clinical educators to be more familiar with simulation research.

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20 thoughts on “Simulcast Journal Club March 2020 – Conceptual Framework for Development of Debriefing Skills

  • Belinda Lowe

    What an interesting article! I’ve previously had such ‘light bulb’ moments in discovering the Dreyfus model. I’ve found this particularly helpful in the past reflecting and discussing procedural skill acquisition. I was intrigued at how this could potentially translate to the development of debriefing skills.

    Vic shared this article with our EDGE group on the Gold Coast (Educate the Educator meeting) posing the questions to us all – what stage are you at with your debriefing and what’s between you and better? I read the article with great interest and a lot of self reflection. There is so much in this article that resonated with me and my journey through learning debriefing skills.

    I was interested in the authors’ discussion around transitioning the tradition 5 step model to the 3 stages of discovery, growth and maturity. It did make me curious though whether the 3 stages were specific enough and whether it might have been helpful to break things down even further. I wondered – was there even enough points to consider a 5 stage debriefing model?? – could this be even more specific and detailed for those of us part way through this journey wanting detailed advice to improve??

    I decided to sit down and write what a 5 stage model would specifically look like to me. Interestingly in doing this – I also reflected that my personal debriefing skills are actually at different stages depending on the type of debrief ie whether I’m debriefing medical students, clinicians who work in my area of clinical expertise vs larger multi-disciplinary groups or clinicians of varying clinical backgrounds. It also helped me reflect on the specific skills I need to master/improve – to move forward.

    A huge thank you to the team of authors for such an interesting article!

    Novice
    – Just trying not to look stupid
    – Rigid adherence to preformed debriefing scripts
    – Needs significant help from supervisors/Co-debriefers to formulate discussion topic points
    – Unable to manage unexpected debriefing points

    Advanced beginner
    – Aware of differing models of debriefing – PEARLS/Plus delta/DASH and outlines for these
    – Can self identify points to be discussed during the scenario
    – Difficulty in managing unexpected learning points highlighted from learners in vent phase
    – Tends to focus on specific points/content – rather than entire picture

    Competent
    – Comfortable with the structure of differing debriefing models and rigid structure transforms more to a fluid conversation
    – Has the flexibility to start to switch focus depending on learner needs in vent
    – Able to draw on techniques such as advocacy inquiry to discover frames
    – Can find it difficult to manage unexpected difficult debriefing situations/conversations
    – May start co-debriefing less experienced de-brief staff

    Proficient
    – Perceives deviations from normal debriefs – able to begin to utilise difficult debriefing strategies
    – Increasingly comfortable with techniques such as AI
    – Have an ability to start ‘thinking on their feet’ to address unexpected learning points or events in the simulation and debrief
    – Gain reflection and can improve skills watching others debrief
    – Increasing skill co-debriefing aiding and assisting less experienced de-briefing staff

    Expert
    – Not helped by rigid structures like proformas
    – Comfortable with being uncomfortable – effortlessly handles the unexpected
    – Ability to think on the fly and utilise creativity
    – Has intuition and invention – eg adjustment of a simulation and or debrief during the event, may decide to ‘redo’ particular parts of scenarios or dive into specific learning or systems issues not initially identified in planning
    – Utilises debrief techniques with great skill
    – Able to very effectively co-debrief

    • Ben Symon

      Hi Belinda,
      Thankyou so much for such a wonderful start to this month’s discussion, I’m very grateful you went to so much effort.
      Now that you’ve drafted a 5 stage model, what do you think of it? Did breaking it into 5 stages allow you to reflect on your personal development with more specificity? To me, reading it, I enjoyed some of the subtle differentiators you mention : that an expert is a great co-debriefer, that they are comfortable being uncomfortable… etc.
      I think this very much harkens back to the concept of adaptive expertise outlined within the article, and it was something that really resonated to me. Much the same way I admire PEARLS for being open to a variety of teaching and facilitation strategies, I think this concept of adaptive expertise frames in my head the idea that an element of proficiency involves allowing control of the conversation to others, such as the learners, because you trust that you can steer it if the ship goes off course somewhere rocky. There’s been a few times where I’ve been debriefing with experts, where it has just felt like flying, you can feel this sense of safety but freedom at the same time.

      • Benjamin Symon

        Hi all,
        Our discussion on this paper paused on March 17th during the COVID outbreak, but we are now restarting the discussion during May. Please feel free to continue commenting.
        Ben

  • Beth Thomas

    Hi Ben, I saw on twitter you were restarting this. Thank you! I welcome having something else to think about. So here are my thoughts on the paper and the subject in general.

    I have previously found myself frustrated at the absence of existing guidance on how best to cultivate novice to expert debriefing performance, given the current breadth of standards describing the virtues and required components for faculty development, yet a lack of predefined measures of competency, proficiency or expertise. I also feel, as influenced by my interpretative lens, that there is a lack of understanding of what expert performance is as it seems to be conceived differently by different people and that this is highly contextual. So for me, this was a very timely and welcome article to read. I was particularly drawn to the notion of adaptive expertise which subtly implies that expert performance could be multi-faceted.

    While Dreyfus and Dreyfus (1986) is one of the most influential models of skill acquisition, I am not convinced that it translates well to the development of debriefing practice, and I think this model oversimplifies the development of this complex and dynamic skill. It is a useful starting point because it conceptualises the development of debriefing expertise as an accumulation of defined knowledge and skills that is advanced by concrete experience. However, it does not explicitly address how one transitions from ‘routine’ to ‘adaptive’ expertise, which I feel is one of the issues of our local faculty development programmes. Nor does it explain why ‘adaptive expertise’ can be achieved by some, but not by others, regardless of their commitment and experience. If anything, the linear development of ‘routine experts’ could impede the development of ‘adaptive experts’ (Mylopoulos and Regehr, 2009).

    Upon reflection of the continual evolution of my debrief practice and now being responsible for developing others practice, I agree with the authors’ comment that faculty may not acquire the knowledge and skills required in such a linear, step-wise manner, and that their prior experiences may influence the trajectory of their development. It is also my experience that faculty do often begin equipped with prior skills and experience that can translate to debriefing, thus trying to situate them within one of the five stages would be challenging as they exhibit features of multiple stages.

    I think the proposed model conceals, what Dall’Alba and Sandberg (2006) argue is a fundamental dimension of professional skill development – namely, ‘understanding of, and in, practice’ (Dall’Alba and Sandberg, 2006, pp.338). Professional skill is referred to by Dall’Alba and Sandberg (2006) as the skilfulness with which professionals engage in practice, and that practice is dynamic and pluralistic in nature, and cannot be meaningfully separated from the situations within which we practice. If we were to consider Heidegger’s (1927/1962) philosophical construct of understanding as an ‘unfolding circulatory’ (Dall’Alba and Sandberg, 2006) – that our understanding of debriefing practice is developed through our interpretation of it, and that interpretation is a means of understanding embedded within the context we practice that clarifies what we have already understood about it – then this may help us understand why there are many different approaches to debriefing and faculty development, and why faculty, regardless of their level of experience, understand and engage in debriefing practice in contrasting ways, which would therefore give rise to variability in the trajectory of debriefing skills development.

    While the authors’ have recognised that approaches that foster metacognitive skills in critical thinking and reflective practice will promote the acquisition of ‘adaptive expertise’, this is in conflict to the underlying premise of the construct which heavily reinforces traditional forms of instruction that begins with the provision of foundational knowledge and ‘rules’, followed by the accumulation of content and context-specific knowledge through experience. In contrast, I am drawn to the “practice development triangle” for debriefer development proposed by Krogh et al. (2016) which supports a shift in focus from microskill development towards approaches that cultivate values and developing artistry. While I think this framework is better suited to accommodating the dynamic, intersubjective and pluralistic nature of practice, it still does not articulate how one’s debriefing practice develops over time and how skilful ‘know-how’ or ‘artistry’ – the hallmark of expertise – is achieved. Therefore, I feel there is a need for developing a multi-dimensional framework for the development and enhancement of debriefing practice that also takes into account Dall’Alba and Sandberg’s (2006) conceptual model of professional skill development. To facilitate this, empirical investigation is required to extend and deepen our understanding of the qualitatively different ways in which debriefing practice is understood and realised. I look forward to hearing other’s thoughts on this.

    Dall’Alba, G. and Sandberg, J., 2006. Unveiling professional development: A critical review of stage models. Review of Educational Research, 76(3), pp. 383–412.

    Krogh, K., Bearman, M., Nestel, D., 2016. “Thinking on your feet”—a qualitative study of debriefing practice. Advances in Simulation, 1(1), pp. 12.

    Mylopoulos, M. and Regehr, G., 2009. How student models of expertise and innovation impact the development of adaptive expertise in medicine. Medical Education, 43(2), pp. 127–132.

    • Ben Symon Post author

      Beth, thank-you so much for restarting discussion with such a beautifully thought out and challenging response to this paper that digs deep into the challenges in leading faculty towards adaptive expertise over routine proficiency. (I also think you’re our first ever response that comes fully referenced!). I’ve CC’d in some of the authors on twitter in the hope that they’ll chime in with some thoughts as well, because I think you highlight some really interesting perspectives on how we learn to get better and the complexities around the way we reflect on our own development.

      Given that you are extensively involved in faculty development, can I ask for some practical tips that you might have found useful in shifting debriefers towards adaptive expertise? What I’ve heard from your response is that a focus on microskills development over ‘format’ and ‘rules’ can be useful, although my perspective would be that those same rules can be useful scaffolds to hang future artistry as well. Any further wisdom to add?

  • Susan Eller

    Hello Ben and friends – what a rich discussion thus far this month. I hope Ben and Vic will understand if I take a metatextual slant on my response 😉

    I have read this article several times during my own doctoral work and as a reference for a group project, and reading Belinda and Beth’s comments caused me to reflect on it even further.

    I first read the article as someone who does faculty development, and was interested in the model. Coming up through the ranks of both nursing and medical education, I was very familiar with Dreyfus and Dreyfus, and the nursing adaptations by Benner. The proposed conceptual framework adapted a widely recognized framework to discuss development of debriefing skills. This use of the familiar decreased my cognitive load when thinking about faculty development. I applaud Belinda for expanding the model to five levels for her own further reflection,

    My second context for reading the article was to examine the structure of that the authors used for articulating their conceptual framework. I also was struggling with semantics, it seemed to me that what medical education called a conceptual framework was what I had learned as mid-range theory in the nursing discipline. Cheng et al. (2019) cite Bordage’s (2009) view of conceptual frameworks as way to shape thinking around a specific issue by explication of the inter-relatedness of the variables and outcomes. I want to thank Walter Eppich, who steered me towards Varpio et al.’s article The Distinctions Between Theory, Theoretical Framework, and Conceptual Framework (2019). This article describes a conceptual framework as a justification for why a study should be conducted, and includes: a description of known knowledge, identification of gaps in understanding, and declaration of the methodological underpinnings of the research project (Varpio et al., 2009).

    Reading both Belinda and Beth’s comments gave me an “aha” moment that this was the true beauty of the Conceptual Framework (Cheng et al., 2019) article. It served that latter purpose. When I first read the article, I was looking at it as an explanation, after reading Varpio, I realized it was an exploration – that invited further discussion and clarification. As someone interested in qualitative research, I was thrilled that Beth mentioned the Krough et al. article – not sure how I missed that the first time. I also was intrigued by the possibilities to use qualitative inquiry to further refine the model as articulated by Cheng et al.

    That’s my novice geeky take on the article and the discussion. I am including the references as I really liked it when Beth did so – what can I say – #PhDlife 😉

    Bordage, G. (2009). Conceptual frameworks to illuminate and magnify. Med Educ, 43(4), 312-319. doi:10.1111/j.1365-2923.2009.03295.x
    Cheng, A., Eppich, W., Kolbe, M., Meguerdichian, M., Bajaj, K., & Grant, V. (2020). A Conceptual Framework for the Development of Debriefing Skills: A Journey of Discovery, Growth, and Maturity. Simul Healthc, 15(1), 55-60. doi:10.1097/sih.0000000000000398
    Krogh, K., Bearman, M., & Nestel, D. (2016). “Thinking on your feet”—a qualitative study of debriefing practice. Advances in Simulation, 1(1), 12. doi:10.1186/s41077-016-0011-4
    Varpio, L., Paradis, E., Uijtdehaage, S., & Young, M. (2019). The Distinctions Between Theory, Theoretical Framework, and Conceptual Framework. Academic Medicine. doi:10.1097/acm.0000000000003075

  • Christina Choung

    Whoa, this month’s journal club is deep and highly academic! Thanks for everyone’s expertise – I’m learning heaps and I must admit I’m rather intimidated to post. But here goes nothing…

    Belinda, I agree with you that upon reading the article I also thought a 5-stage model could be achieved. I love how you’ve taken the time to parse it out and I think it’s marvelous. (My favourite: “Just trying not to look stupid” – been there!) Anytime someone mentions Dreyfus and/or Benner I can’t help but think of competency frameworks and when I first read the article, I found it a bit perplexing as to why one wasn’t included or offered – especially given the way the article lays out each stage with “Debriefer Characteristics, Knowledge, and Skills,” and also knowing that these authors have offered other debriefer “checklists” in the past (the Peer Coaching checklist and Co-Debriefing checklists come to mind). In my head a competence assessment, planning, and evaluation (CAPE) tool was being formed. But then I thought of existing debriefing competency tools (OSAD, DASH) and how much I don’t like using them because I find them too prescriptive and cumbersome – which I think may be reflected in Beth’s post, and more specifically when she speaks about development not being linear and the need for a “…multi-dimensional framework for the development and enhancement of debriefing practice,” and when both the authors and Belinda speak to fluctuating abilities based on context. I agree that more research is needed but I also believe – and this may be a total cop-out – that debriefing is a “science and an art”. There’s a piece of faculty development which I sincerely think is really challenging to “develop” in some folks and that’s the genuine curiosity and high regard we often mention. I think that sincerity, coupled with adaptive expertise, is what makes up the “art” and plays a huge role in debriefing. I think it’s also well reflected in the Krogh article that’s been mentioned.

    I do really like the discussion in the paper about faculty development strategies and thinking about which methods are useful when. I don’t necessarily agree with Figure 1 but I think it’s a great jumping off point for discussion and further thought. I think it’s missing keeping up with literature and the sim CoP (although maybe those are captured under some of the other categories?), although those are mentioned in the article itself. Some colleagues had a good discussion about what they find intriguing about the figure, at around 12:45 of this journal club recording (which has some great discussion questions): https://bcsimulation.ca/video/CICSL-JC-14Jan2020.mp4

    I also wonder about the piece surrounding “becoming comfortable with the uncomfortable” and how it translates into faculty development. It isn’t really a part of the article but it’s certainly a piece of debriefing which again – I’m not sure how well is able to be taught or developed. Certainly knowing that it’s something which we all live with can be reassuring, but in my experience there are people who are just not okay with discomfort and that stagnates them in their debriefing – and overall simulation – facilitation journey.

    I appreciate Susan’s post and the explanation of Conceptual Frameworks as being a place to generate discussion – which I think this article certainly has! I’d love to hear about how others decided on how to structure their faculty development courses. When I was working at VCH, our team put courses together as we saw the need unfolding. We did purposefully think about how to scaffold learning and in what order folks should receive training along with what types of resources would be helpful (all the “strategies” mentioned in the article), but it was never written down and articulated in the way the authors have done so here. And while we encouraged peer feedback and self-reflection, it was never really “mandated” – adult learning principles made it so that we’d leave it to others to decide how they would choose to develop their skills.

    What are others’ thoughts?

    • Jessica Stokes-Parish

      Wow, what a fantastically “meta” conversation so far – there has been some deep thought put in here! I, too, am almost intimidated by the depth of discussion and theory raise.

      To bring it back to practical application – one thing that strikes me around theoretical discussions of anything simulation/learning related is that each of us does interpret it to our individual setting – which is part of the unique beauty of simulation based learning. So in this instance, how does this concept apply to my setting? What does that look like? To me, it reinforces the need to have a consensus group of simulation experts in our individual settings; this consensus group could “set the standard”, if you will. If I bring together the collective experiences (whether novice or expert) in my clinical setting, what does that look like? E.g. a small hospital centre would presumably be resourced by a clinician who spends 0.2FTE on simulation versus a tertiary centre with a staff of 6. In this instance, could our definitions of novice or expert change to suit the setting? And, secondly, presumably our definitions of novice>expert would change as the broader simulation community’s knowledge deepens. So if this I the case, can we map a strategy in advance, or just-in-time as @Christina highlights?

      • Victoria Brazil

        Hey thank you all for the wonderful conversation so far.
        A recap (for myself) ….but maybe helpful to others….
        • Cheng et al offer us a conceptual framework for debriefing skills including phases of discovery and growth and maturity, and especially highlights the aim of adaptive expertise.
        • We wonder if maybe 5 stages of the model would help delineate the journey better?
        • We take a deep dive into models of skill acquisition but are encouraged to be wary of oversimplification.
        • Krogh’s great paper on debriefing practice is mentioned.
        • We take another deep dive into what a conceptual framework is!
        • We reflect on the challenges of using assessment tools for debriefing practice.
        • And we are reminded that this ‘adaptive expertise’ means that our debriefing needs to be context specific
        So – with all that in mind, my personal view aligns with Beth – it’s difficult to describe a model of skill acquisition when ‘expert’ skill performance is itself so hard to define. Debriefing is much more than the ‘sum of the parts’ and hence I share Christina’s discomfort with the ‘tools’, and maybe why the Dreyfus model suits central lines more than debriefing conversations.
        I am very fond of Kris Krogh’s model – artistry, values and skills are required to support reflective practice conversations for individuals and teams.
        After a wonderful chat with the team from Queens university in Belfast last week ( for an upcoming episode), I’ve come to think about the overly prescriptive versions of debriefing conversation as ‘hyperreal’ conversations – an example of Baudrillard’s ‘simulacra’. Read here….https://onlinelibrary.wiley.com/doi/epdf/10.1111/medu.14184
        And wait for the episode !
        Thanks again everyone.
        vb

        • Ben Symon Post author

          Thanks all for this marvellous discussion!

          I want to just take a moment to highlight that a number of people are mentioning they felt intimidated posting, and I’m grateful to you for expressing that as I suspect there’s other readers out there a little overwhelmed at the academic nature and depth of the posts this month. I just want to flag that while I’m incredibly awed at the post quality this month and grateful for the people who have taken the time to consider this paper so deeply and reference their posts, It’s totally ok if you’re new to the journal club and just feel like posting a quick “here’s what I think” post or just say hi, or to ask a question of this group of very clever people we’ve accumulated this month!

          • Ben Symon Post author

            I guess to me reading these comments, a prominent theme is the debate between whether adaptive expertise is something you construct sequentially or whether an emphasis on artistry and micro skill development may lead to a richer debriefing palette to work from.

            I like the use of this article as a calibration technique and prompt for reflection, but I also hear the debate about how effectively it can be used as a development tool.

            Further thoughts on this?

    • Ann Mullen

      I’ve been reflecting on Christina’s point about “becoming comfortable with the uncomfortable” and how it translates into faculty development. I think that it is a lot to ask of people to be comfortable in difficult situations; instead the goal is to avoid getting derailed by the discomfort. Firefighters don’t feel comfortable entering a burning building, yet they know that they have the tools and skills to do so. This is definitely a skill which can be developed by self-awareness, reflection, and feedback.

      If I were trying to help a colleague, I might start with this: What types of situations make you uncomfortable? Hierarchy, conflict, identity threat, etc are common triggers. There may be more under the surface. Hmmm, this person reminds me of someone in my life that I can’t stand! I have to work with these people every day, and I don’t want to damage my relationship. Conversely, what makes you feel confident? Thinking about situations where you are at your best can help you learn more about yourself. What drives you? What feeds your passion?

      It is also useful to anticipate challenges that may come up in the debriefing and do a bit of rehearsal ahead of time, perhaps using an if/ then statement. For example: If the conversation gets heated, that means that people really care about this and we can learn from it. If the going gets rough, I’ll remember the basic assumption and get curious.

  • Debra Nestel

    I got drawn in way too easily. Thanks for creating that invitational quality! I want to keep it brief.

    Enjoyed reading the Cheng et al (2020) article. Loved Ben’s vignette. Really thoughtful contributions from everyone – Ben, Belinda, Beth, Susan, Christina, Jess, Vic . Mine is way less “considered” so I apologise. I’ve also moved away from the original request (a little).

    I’ll throw a few things into the mix:
    I’m moving away from a focus on ‘debriefing’ to one on ‘learning conversations’. While it might seem like some educationalist doing word play – it’s so much more. It’s ironic to me that a community that still holds so tightly ‘non-technical skills’ (those who know me realise how hard it is for me to write this) then goes about treating ‘debriefing’ as a ‘technical skill’ – see most faculty development programs – tips and tricks, sequences, parts etc… The ‘learning conversation’ phrase feels far less formulaic.

    Just a note, it’s not Krogh or Kris Krogh Model – the ‘practice development triangle’ comes from Handal G & Lauvas P. The “practical theory” of teachers. Promoting reflective teaching: supervision in action. Milton Keynes: SRHE and Open University Educational Enterprises Limited; 1987. p. 9–29. They wrote a few articles with a strong sense of promoting reflection of teachers in their practices. Krogh et al shifted this a little to help us make sense of what experienced simulation educators were telling us about how they developed debriefing expertise. The privileging of personal values I think needs to be addressed early on in faculty development. Everything else stems from that and we need to keep returning to them and how they manifest in what we actually say and do (not what we think we say and do). The artistry – that idea that you’ve a colourful palette and brushes from which to choose, how will you get the tone and texture to the canvas that will achieve the best effect – is what faces the debriefer as “they think on their feet”. Experienced debriefers described it beautifully and were “being comfortable with the uncomfortable” (Krogh et al, 2016) The Krogh et al (2016) article is still one of the only studies that focuses on how experts develop expertise in debriefing. It’s curious it did not inform the Cheng et al article in anyway. Truly genuine curiosity.

    I love the notion of routine and adaptive expertise, first described in observational work with sushi chefs. See Hatano, G. and K. Inagaki (1986). “Two courses of expertise.” Child development and education in Japan: 262–272. It’s worth reading around the concept (even a quick Wikipedia read) and how it was originally described!

    Here’s another concept I once visited – workmanship of risk and workmanship of certainty first described by David Pye, a professor of furniture design – a wood carver and designer. He described these concepts relative to the impact of industrial scale woodwork on craft practices. I wrote about this with Tim Dornan with respect to thinking about medical education practices and their consequences. Dornan, T., & Nestel, D. (2013). Talking, touching, and cutting: The craft of medicine. Journal of Modern Craft, 6(1), 35-48. In a move to mass production we can lose the essence of artforms. That many of our training approaches should focus on training for workmanship of risk. In debriefing, we should be aiming at preparing debriefers (and debriefees) to thrive in this notion of workmanship of risk. I’ll have to deal with the gendered term but that’s for another time!

    I think the PhD work of Christina Johnson on feedback in clinical settings has really helped (liberated) me to move away from thinking about debriefing to thinking about what I ‘am’ (thinking/doing/feeling/projecting) before, during and after a simulation in setting up and then managing a learning conversation. I also use the word managing rather than facilitating (or controlling – somewhere in this thread). Here is a recent article from Johnson et al https://onlinelibrary.wiley.com/doi/abs/10.1111/medu.14154

    Back to Cheng et al, I wasn’t sure there was capacity for discovery in maturity phase. Maybe I’m still in the discovery phase after all.

    • Beth Thomas

      Hi again and thanks all for posting and contributing to this highly stimulating and enjoyable discussion which I have found refreshing. And while I didn’t mean to be a trendsetter, I have really appreciated people’s reference contributions too, as they have been a helpful reminder that context matters. While we can learn so much from the work of others and from other fields and disciplines, we would do well to remember to consider the context within which they were originally constructed (built upon or embedded within) as we try to apply or make sense of them in our own settings, and being reflexive of the differences between the original context and ours now. I also find this helpful to remember when utilising and applying tools too, and with so many options available out there I wonder how others have managed to addressed this within faculty development. Can one match the right tool to suit themselves as a person (their values, world views etc.) and their context for that moment in time? Is this what is adaptive expertise or thinking on your feet? Hence, I am really keen to hear people’s shop floor experiences, and I hope all followers can feel encouraged to contribute and share your own context, experiences, observations and reflections rather than literature. For example, I’m also curious about why often people may not deem themselves to have expertise in debriefing practice, but others consider that they are. I know I feel this way, and this reinforces my view that we should try to be attentive to the subjective, contextual and pluralistic nature of debriefing practice, and consider how best we can do this? And so I really like Debra’s proposed reframing to ‘learning conversations’. In my practice I thoroughly enjoy engaging in reflexive conversations with others on my practice (though I almost always have to instigate the conversation, as people don’t voluntarily come to ‘debrief my debrief’). And I am particularly open to doing this with anyone no matter where they are on their debrief journey, even if they are just starting out. In doing this, I hope that it encourages them to do the same. Though I must admit that I do find it harder and harder to break down aspects of my practice which I suppose is the artistry or adaptive expertise component, but then I think that this is what makes the exercise even more valuable for me and those who I am supporting in their development.

    • Ben Symon

      Debra, thankyou so much for dropping by and clarifying & deepening the discussion, while also luring us towards further learning :p
      I’ve been unsuccessful in trying to lure in Kristian at the moment, so I’m very grateful for you joining us!

  • Ann Mullen

    This article explores one of my favorite topics, beautiful written by some of my favorite people! I have been a fan of the Dreyfus & Dreyfus model for a long time, because I found to to be practical and applicable to my work as a nurse and an educator. Lots of stuff to think about here. I agree with Susan Eller; my familiarity with the nursing applications by Benner made it easier for me to think about reimagining the Dreyfus model in the three categories of discovery, growth and maturity. I also liked the case illustrations of debriefers at each stage.

    I am aware of a recurring theme that I think is relevant to this discussion of skill acquisition. When one knows what it feels like to be a mature practitioner, it is very uncomfortable to take on a new skill and be in the discovery phase. I first noticed this when orienting experienced med-surg nurses to the ICU. In their former role they were the go-to person on their unit when questions or problems arose. In their new role, they were the one asking all the questions!
    Another example: a skilled and mature anesthetist is invited to take on a new role as a simulation educator. She is accustomed to doing her work every day with ease and fluidity. As she struggles to facilitate a debriefing, the discomfort can be quite unnerving, I’ve heard people say “Apparently, I’ve forgotten how to speak English”
    I find that explicitly discussing the stages of skill acquisition can be helpful. When I brought it up with nurses, they were often quite relieved to talk about that, because they had been feeling quite inadequate and worried that they were failing. I think that the structure offered in this paper can be useful to frame those conversations. One might say “Because you are in the growth stage of your development, tools and scripts can be quite useful.”
    Interested to hear from Journal Clubbers on this!

  • Jenny Rudolph

    Hello Ben,
    Once again, thanks for creating this space for reflection and learning. As a sociology major in college I am LOVIN’ this meta textual dialogue. BUT as an athlete and coach and someone who has to get better at coaching debriefing as part of my job, I thought I would ask for some practical help on a dilemma this month’s article and conversation raised for me.

    Helping Novices: Balancing adherence to process/technique versus keeping ones eyes on the prize, the goal?

    I found Adam Cheng and team’s conceptual framework for developing debriefing skills engaging and helpful. I especially liked Table 1 as an aid to developing debriefing faculty because it highlights how the cognitive load of juggling process, technique and goals is formidable.

    Adam, Walter, Michaela, Michael, Komal and Vince wisely counsel that when novices focus too much on process, such as phases or phrases for debriefing, they lose sight of the goal of debriefing—having a learning conversation!

    How to balance coaching for adherence to technique (that has been generated by expert experience) versus a focus on larger goals for early learners? I think this is a fascinating challenge in any conversational skill such as debriefing, goals of care conversations, taking a history, aligning expectations in a consent conversation, and perhaps running a code. Adam Cheng et al’s paper, and some of the dialogue on the journal club got me thinking! How do I think about this?

    Here is how I answered: When coaching rowing and swimming I had a go-to “trick” for managing the “technique versus goal” challenge. I would talk to experts or figure out for myself what was the “heart” of the technique. If I could teach novices the “heart” of the technique, they would immediately be doing a core skill that moved them toward the main goal. In both of my examples, moving through the water as fast as possible. For swimming the butterfly, a notoriously complex stroke, I learned to learn and teach this by watching a children’s swim coach teach five year-olds the stroke in 20 minutes. The heart of it? The dolphin-like sine wave motion. Everything else about the stroke can easily be added on to that. In rowing crew, the heart of the stroke is “connecting” your oar with the water (not ripping your oar through the water). The technique to accomplish this is to imagine and physically feel that rowing is like a pull-up, only horizontal. Every other part of the stroke, feathering your oar, gliding to the front of the stroke etc. can easily be added on to that.

    I have also tried to find the “heart” of debriefing to help myself and others learn and teach it. I may or may not have succeeded, yet. In my opinion, the heart of debriefing, when directed at performance improvement or sustainment is to simultaneously hold onto the standards you want to help learners reach (or sustain) and, at the same time, assume the best of them, hold them in high regard. This is because, I believe, if you can hold high standards and high regard, you will neither shy away from the most important topics nor be too harsh, and everything else–phases, phrases, techniques if you wish–can be added on easily.

    However, the challenge for the several thousand novice debriefers I have worked with is that, unlike learning to swim in the shape of a sine wave, or “hang” off your oar, holding high standards and high regard can be a bit mind-bending at first.

    Because it is mind-bending, I make the assumption that having a technique and seeing the positive and surprising impact of the technique (preview, advocacy, inquiry, listen) will give newer debriefers the dopamine squirt to start their being “addicted” to this counter-intuitive approach. When they say what they think and ask others what they think, they often get surprising and generative answers that help them know what to do or say next (hence the dopamine squirt). Thus, I often guide them to adhere to combining previewing, advocacy ,inquiry, listen because I think this helps them discover what all of their socialization has taught them to doubt: that you can be honest and non-threatening; you can care personally while challenging directly (as Kim Scott says in “Radical Candor”). You can hold high standards and high regard.

    As Cheng et al. note, however, coaching newer debriefers to adhere to any technique whether advocacy inquiry or phases or pros and cons can sometimes backfire because the newer debriefers lose sight of the bigger picture goal, having a learning conversation.

    Since there a many readers in this conversation who teach clinical procedures, conversations, debriefings, I would love to hear how others think about balancing helping newer learners understand and reach the main goal and also learn to use established techniques?

  • Ben Symon

    I just want to take 5 to sit back and look in awe at the discussion this month. I’m so beyond privileged to be blessed with such wise and thoughtful comments from the group of people who have joined us. I’ve facilitated less than usual because the group has directed the conversation so magnificently that I could rarely think of a value add, and it was flowing in such a lovely manner that I didn’t want to derail it. In doing so though, I wanted to make sure how much I appreciate all your comments. Belinda, thankyou for starting this month’s conversation with such an enthusiastic and diligent response. Beth your analysis and thought provoking challenges to the underlying principles of the paper have opened up this month in a way I would have never predicted, and it’s been wonderful. Susan, thankyou for coming every month and empowering me with your enthusiasm. JSP and Christina thanks so much for combining the practical with the academic in such helpful ways. VB cheers for summarising so succinctly the issues and ensuring our ‘lurkers’ are recapped effectively. Debra, your guidance through new and old concepts was so helpful and clarified a number of my own misunderstandings. Ann, I love it every time you join us and your thoughts on the discomfort of moving back to the discovery phase helped crystalise the importance of empathy when dealing with expert learners in new environments. Finally, Jenny, I loved your analogy of ‘the heart of the matter’, and the argument that focusing on a pivotal concept can provide a structure to hang future skills on.

    I know I’m rambling a bit, but honestly, sometimes you just have to pinch yourself, right?