Simulcast Journal Club September 2018

Simulcast Journal Club : September 2018 

Introduction :  

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

For the journal club to thrive we need your comments!  Some participants report feeling nervous about their initial posts, but we work hard at ensuring this is a safe online space where your thoughts are valued and appreciated.  To ensure this, all posts are reviewed prior to posting.  We look forward to learning from you. 

Journal Club

Title :  “Explicit Thoughts 

Nimali had sat herself opposite Catherine in the debrief circle, ostensibly to maintain good eye contact with the whole group but secretly she was quite relieved that Catherine was lead debriefer.  Deciding how to tell her husband that she’d kissed a co-worker and then… debriefed with very bad judgment was weighing on her mind much more than the current group’s middling performance in a withdrawal of care scenario. 

Catherine looked over and raised a mischievous eyebrow, Nimali gave an amiable eye roll in return.  Telling Joe would be hard, but he’d have to know it’d been coming for a while.  At the same time her and Nitin hadn’t defined their relationship either.  Nitin was in full puppy dog mode which was gratifying after being married for so long, but sometimes it seemed like he was more in love with his idealised version of her abilities as an educator than her actual self. At the moment it seemed they’d decided to leave the implicit confusion about their explicit behaviours unacknowledged.  She suspected Nitin was scared behind his relentless smiles. 

She glanced up at Catherine and sighed, Catherine gave her a knowing grin.  Thank goodness for trusted friends who could read each other like a book.  She just could not care less about this debrief right now and Catherine knew it.  She took a sip on her coffee mug and started to think back guiltily to the night of the work party.  It had been such a passionate kiss, and Nitin had looked surprisingly good with his shirt off. 

“Nimali!” said Catherine, “You look like you’ve got some strong thoughts about Henrietta’s question?” 

Nimali choked on her coffee.  So much for reading each other like a book. 

The Article : 

Cheng, A., Palaganas, J., Eppich, W., Rudolph, J., Robinson, T. and Grant, V. (2015). Co-debriefing for Simulation-based Education. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 10(2), pp.69-75. 

Discussion :  


Co-debriefing can be challenging for a lot of reasons, and in this paper by Cheng et al, the authors outline a number of potential approaches regarding how to debrief more effectively with a colleague.  Behind that though, is also the theme of ‘above the table of negotiation’, the idea that we can debate the flow of the debrief with our colleagues in front of our learners without significant detriment. 


For our journal club bloggers this month, what challenges do you experience debriefing?  How have you overcome them?  Does this paper help? 


References : 

Cheng, A., Palaganas, J., Eppich, W., Rudolph, J., Robinson, T. and Grant, V. (2015). Co-debriefing for Simulation-based Education. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 10(2), pp.69-75. 

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.

36 thoughts on “Simulcast Journal Club September 2018

  • Christina Choung

    Hi Ben,
    Thanks for your great storytelling, as always!
    I was pretty stoked when this article came out – some might say it isn’t “academic” enough, but a primer is especially useful for practitioners such as myself, and those we help coach. I really like the design of the article and the figures – makes for easy application and understanding. It reads like a “tips and tricks” paper – practical and to the point.
    We promote co-debriefing at our site, particularly for team-based simulation scenarios, for the reasons listed in the paper. In one of our formal education workshops for new graduate nurses (I wish it was multidisciplinary, but unfortunately we recieved funding only specifically for nurses), we run simulations where healthcare educators co-debrief with real patients. Who will be co-debriefing with whom changes from workshop to workshop, as there’s a rotation of different folks in each role. In order to equip the healthcare educators and the real patients with the basic theory, practice, and tools required to do this, and to ensure a shared mental model, part of their training included reading this article, discussing it as a group, developing tools and aids based off of this article, practicing together prior to workshop launch, and ongoing coaching. Now, prior to every session for the new grads, the healthcare educator and real patient will meet prior to the sims, go through an adapted co-debriefing checklist (figure 2), and decide on which type of co-debriefing structured approach they would like to use. Post-event, they will once again bring out the modified checklist for peer/self feedback and review. This has been working well.
    On the other hand, in more clinical settings, we’ve often come across co-debriefers who are not on the same page at all! Having this article as something tangible to hand them, and to draw from, has been really helpful. Prior to this, during meta-debriefs it would be hit or miss when I would throw out a suggestion – I found much of it depended on the dynamic between the co-debriefers, or whether or not I was perceived as an “expert”. If one was clearly lower in the hierarchy of the unit, or disliked somewhat uncomfortable situations, they would always defer to the other. However, if I point to this article and bring it with me, I tend to get more buy-in from those who were previously more resistant, or more agreement from those who were afraid to speak up, because it’s printed in black and white and from an actual sim journal.
    As a last point – in addition the things mentioned above, the other tips which people tend to like the most are: the use of pre-determined hand signals when someone wants to chime in, the “do you have anything add, Jane?,” letting the scenario continue a little longer in the “denouement” phase so co-debriefers have a chance to do a quick pre-debrief chat, and having co-debriefers sit across from each other so they can see not only each other clearly, but so they also have a different point of view of the participants in the debriefing circle.

    • Ben Symon Post author

      Thanks Christina for starting the conversation! I agree this is a foundational paper that is really useful at quickly orienting new debriefers on how to work together effectively. I was interested that you actually use this article as a pro-active tool for getting people up to speed though, I would have thought it’d be hard to get people to read a paper on the day of their scenario. How do you find that goes?

      • Christina Choung

        Sorry, I should clarify – I don’t usually ask people to read it right before the scenario. There’s a few ways I bring it up, and we try to use motivation as a key factor.
        If it’s someone who’s new to leading sims and is attending our simulation facilitator course, we mention it there. Usually those who have had a less-than-ideal co-debriefing situation in the past will be interested in the article. After the course, when we move onto “IRL” coaching, we’ll refer to the terminology and concepts in the article as a guide.
        If I’m at a sim to provide meta-debriefing and either myself or the debriefers make note of a feeling or instances of asynchrony between the co-debriefers, I’ll mention the article and send it to them immediately afterwards via email. The next time I’m there to meta-debrief, I’ll bring up the article prior to the sim to see if the team wants to deliberately use any of the methods.
        Rarely, one co-debriefer will feel as though the other is exhibiting one, or some, of the challenging behaviours mentioned in the article. Even with meta-debriefing and feedback, due to whatever reason, the other does not see their behaviour as a problem – there’s a misalignment in debriefing philosophies. In those cases, if I’m coming back to meta-debrief with the team again, I will bring a physical copy of the article with me because, to be honest, I don’t trust that the person who feels that nothing is wrong will have read the e-copy. I’m trying to increase the likelihood that they’ll engage with it. But to be honest, I’ve only done this once and I’m sad to say it hasn’t panned out.

        TLDR: For most clinicians, I usually give the paper out after people have experienced difficulty co-debriefing, because I think it increases the likelihood that they’ll read it.

        • Ben Symon Post author

          Wow Christina, sounds like they’re lucky to have you! Your passion for the article and improving your team is clear. Is this article the one you share most?

          • Christina Choung

            Hahaha, thanks Ben!
            The article we use most widely and set as a must-read/foundation would be PEARLS, followed by the Safe Container article. You’ve covered them both! =)

  • Derek Louey

    Hello Ben

    It was only last week that a group of us had organised a simulation-based teaching course when this issue came up!

    I was about to facilitate a scenario that I had designed for my group, when at the last moment my colleague became available to offer her assistance. Although the general themes and goals of the course were clear and the level of the participants were evident, she was not entirely familiar with how the scenario ran. As a consequence, it was probably difficult for to participate as an informed confederate but I suggested that she could assist with the debriefing afterwards. I was confident that she could handle this with very little pre-briefing and I thought it would be interesting to see her approach to it.

    Nevertheless, she declined stating that she felt that since I had written the scenario, it would be unfair for me not to debrief it considering I had ‘my own particular style’. Admittedly, I was taken slightly aback by this response reflecting on what exactly ‘my style’ was. During the week we had each observed each other facilitating simulations though never really had the opportunity to co-debrief together.

    However, her comments made me reflect on the implications of this. It raised some important questions:

    Is it a problem that facilitators/debriefers have different ‘styles’? Or should we have a consistent and unified approach to the way we run simulation?
    Is transfer of knowledge invariably worsened when styles or messages diverge?
    Is it vitally important that contradiction does not occur during a debrief?
    Is it problematic that instructors emphasise different learning points during the session?

    There seem to be many parallels in this dilemma with other teaching and clinical encounters e.g. multiple clinicians involved in a patient’s care, when residents on the floor obtain specific patient advice from different supervisors, or when a teaching program involves different specialties and clinicians each with their own perspectives and approach.

    Should we actively manage this? Is it manageable? Is it important that we consistently do this? Or does the messiness of education and clinical medicine enhance effective learning and provides students the critical skills to navigate the often contradictory and nuanced nature of life-long self education?

    • Ann Mullen

      Such interesting questions! I don’t know if I have answers to any or all of them; I’ll share some thoughts.

      Your colleague became available at the last minute, and it would be a shame to miss out on her contributions. However, it presented a challenge that there was little time to discussion how to work together. This month’s article offers us a framework and very practical strategies.

      When I read the comment about your “particular style”, I assumed that it was meant as a compliment. Is it a problem for faculty to have different styles? As long as you are using sound practices, i think not. On the contrary, it is important that we bring our authentic voice to a debriefing. It would be interesting to revisit that discussion to learn more about what she observed.

      The facilitator prebriefing is so valuable, and can prevent misunderstandings and awkwardness during the session. I like to share a personal goal and ask my co-debriefer to do the same. For example, allowing for silence, asking follow up questions, etc. Stating an explicit goal helps me to be more mindful of the goal, and sets the stage for the post course discussion.

      • Ben Symon Post author

        Thanks for coming Ann. So nice to hear from you, I miss you!
        I think you make an important point regarding personal style being the foundation for authenticity as a debriefer.
        I agree the prebriefing is very valuable, I’d have to confess it is probably the most commonly neglected element of the debriefing process in my own centres. The article in particular reminds us to establish some targeted learning objectives, which I find we’re often asynchronous with, particularly when we come from different professional streams.

    • Ben Symon Post author

      Thanks for coming Derek, great to hear from you again. I think Ann’s response captures my personal response towards how streamlined and consistent our debriefing approaches should be ^
      ie. Personal style bring authenticity, excessive variation probably leads to learners feeling a bit off centre.

      • Derek Louey

        I think it depends on the strength of that centre.

        Going back to cognitive load theory, novices tend to prefer simple, unambiguous, consistent and concrete messages. This provides the scaffolding to build their core of understanding. As learners mature they are more able to tolerate contradictory or qualified data. At this point they have enough comprehension (and confidence) to resolve these differences or incorporate that into their (constructivist) framework.

        However, the issue of what constitutes ‘core curriculum’ remains a debated area even in R-12 education e.g. at what point do you learn multiplication tables. So even ignoring teacher styles, there can be disagreement about what are the important and fundamental messages that need to be learnt first or they way in which these /ought/ to be categorised or structured e.g. phonetical spelling or alphabetical spelling

  • Susan Eller

    Hello Ben

    Hmm… I started to answer Christina and Derek’s replies, and realized I was sounding a little like a character from your Novella ;). It was actually in response to the team debriefing and divergent styles of the debriefers. In some way, both questions seem to me as a matter of different voices.

    The debriefing of interprofessional teams: I had a horrible experience in my early simulation instructor days watching a lead debriefer put the participants in rows – first horror; then put the physicians in the first row and nurses in the second – second horror. This was NOT how I was trained as an instructor, and the reinforcement of the hierarchy made me sad. And mad. I have been fortunate to work with individuals who value my expertise, not just as an educator, but as a nurse. When a nurse says “are you sure…” without providing their point of view, it makes me want to cringe. I had one of my physician co-debriefers think that was a good thing because the nurse was trying to speak up. I wanted the nurse to say “I am concerned about that decision because I think it will yield these consequences – can we discuss”. His physician voice (from his own experience and education) was different than my nursing voice. We had a great conversation about it later, and it is something that I bring up during instructor courses as a co-debriefing consideration.

    As for different styles: When I started my current role, I had a very different debriefing style than one of my co-debriefers. I was worried that it would be a problem that I preferred the way I had been mentored. What I learned is that we both had very similar intentions and philosophies about experiential/reflective learning and the debriefing conversation. When I focused on the ways our outlooks and goals were similar, it allowed me to look past the style differences and appreciate the nuances that the different voices could generate.

    I do use many of the proactive strategies listed in the article – not surprising considering who some of my mentors have been in debriefing. However, I will also say that even with the deliberate strategies, it is wonderful to have the opportunity to co-debrief with someone over time – so that you can know their priority issues/topics, can detect more subtle cues in their non-verbal and anticipate the direction they may be headed next.

    • Ben Symon Post author

      Thanks for coming as always Susan, and thanks for coming so consistently too. I’m so grateful to have you along every month.
      I think what stood out for me as a really important learning point from your comments is that different professional streams can often speak different languages, have different priorities, but also (most importantly for me) have different levels of comfort in holding each other accountable. I would argue that anecdotally a nurse is much more comfortable having a confronting conversation with another nurse, whereas when I have concerns about a nurses performance I have a degree of hesitance in coming across as a doctor telling a nurse how to do stuff. Your particular standard mentioned, the wish for a nurse to communicate transparently rather than through ‘hint and hope’ is a great point that I’m going to steal :p
      Secondly I love your point about focusing less about individual style and more on outlooks and goals, I think that’s a lovely way to generate consistency while respecting individual technique.

      • Derek Louey

        We also have mismatched expectations about what each of our professional streams should know or be capable of. As the Consultant-on-the-floor, all manner of staff constantly come up to be solve problems that I neither have the professional knowledge, training or experience to address. Thankfully I generally know who can answer them within the organisation, but that’s a different story….. In a sim sometimes it never seems right to say ‘I’ll refer that matter on’ because it is often a closed system where the ‘help’ never seems to arrive and you aren’t sure if you are working within or beyond your boundaries.


    Thanks, Ben for another fundamental paper in debriefing.

    I was first introduced to this article by my mentor Victoria Brazil when I asked her advice on how to deal with an issue that came up with one of the co-debriefers. This article has changed my perception and approach on how to be a good Co debriefer, thanks to Adam Cheng and his team for such a great piece.
    These are my thoughts on co-debriefing
    Co-debriefing is harder and more complex than solo debriefing. It requires being extremely good at reading facial expressions and body language of your co-debriefer and to know when to pick up the baton and when to hand it back again without disrupting the flow of the session.
    Co-debriefing like any work/ life relationships is built on trust, respect, transparency, chemistry, and flexibility.
    Creating a safe container not only for our participants but also for our co-debriefer is crucial.
    I believe mutual respect and shared goals is a good place to start establishing this concept. This should be followed by transparency and ensuring all negotiations are above the table.
    I utilize the briefing session to discuss and explore with my co-debriefer (both junior and senior debriefers) the following:
    1- What do they want to get out of this session as a co-debriefer and why is that important for them? Converting the What question to SO What? Some might want to improve their team leader skills by running the whole session, others want to get better at giving feedback to their co-debriefer “debriefing the debriefer “and almost everyone wants to improve their debriefing skills.

    2- To discuss and agree on all the logistics of the session including the co-debriefing strategy Who will do what, for how long, what are the cues, when to pause, who will be the lead debriefer who will be the content expert ..etc.

    3- Post debriefing huddle is another great space that allows both co-debriefers to vent, explore new suggestions and give meaningful feedback to each other.
    To answer some of Derek questions I don’t believe that we all need to have the same style but rather a style that is compatible with and complement other styles. Susan also brought up an excellent point of co-debriefing interprofessional teams and its challenges. This was one of the articles future directions and we hope to see a new article from the author exploring this domain.

    • Ben Symon Post author

      Thanks Nemat, I agree that debriefing and in particular co-debriefing requires a high level of emotional intelligence and facial reading abilities. But I think that learning to negotiate above the table can mitigate some of that a little bit. I remember one of my first experiences with above the table negotiation was kind of in a social setting. I received a generic comment from a debriefing expert and thought it must be meant as a personal criticism, my mentor who knew me well stated to the other expert “Ben’s interpreting that as criticism”, and he immediately corrected me and explained his thinking behind the comment.
      It was a wonderful moment in terms of watching two experts who knew each other well negotiate their concerns openly in a social setting, but equally it was a tiny bit odd because narrating someone’s emotional response in front of them is a fairly unusual thing to do socially. I loved it, because it lead to making the implicit explicit and I find above the table negotiation helpful in everything I do nowadays.

  • Janine Kane

    Great article and discussion topic! To be able to co-facilitate and debrief would be fab but funding has a way of ignoring our wants and desires. We are often told to be grateful for having SBE and lots of manikins that go beep(cos it looks impressive). Focus for pre brief and debrief and its value /importance in SBE still has a way to go in many areas. I guess we need to keep on fighting the good fight to get the importance of pre post briefing recognised and then push for multiple facilitators so we can eventually get to co debriefing etc. 😬 I for one would love to be in this position but alas, not yet.

  • Komal Bajaj

    Thank you for prompting me to revisit this classic article. Like a good movie, new things resonated with me this time around.

    This time, I’m thinking about how crucial explicitly including the skill of co-debriefing has been in our own faculty development programs. Along with mastering debriefing structure itself, it’s useful to have opportunity to contemplate the theoretical underpinnings and practice co-debriefing because, as many have said, it’s a new skill. We didn’t always place so much emphasis on it but I”m glad we have evolved to include it. This discussion has forced me to think about new and creative ways to consider its application.

    ps: Great update on the Bob-Nimali-Nitin love triangle situation – I’ll be curious to see how things continue to unfold!

    • Ben Symon Post author

      Hi Komal,
      Thanks for your comment. I agree codebriefing is a specific, separate skill. What strategies have you taught in your fellowship program? Do you utilise the article or do you take a different tack?
      Glad your enjoying the sordid romance :p

  • Victoria Brazil

    Thanks Ben and journal club team !

    I agree that co-debriefing is hard.
    As one who oversights a program involving multiple facilitators with variable training, i hear a lot of complaining ‘after the fact’ about co-debriefers. This is commonly when content experts participate as debriefers without training in group or debriefing process, and yet assume/claim a superior place as a result of content expertise.
    ( and yes there are often interprofessional hierarchies involved as well)

    I find the challenge is in turning the content of this article into action.

    Those ‘aggrieved’ debriefers just want to send this article to their ‘inadequate’ co-debriefers. And yes i’ve found myself with the same thoughts…..
    I’d like a few phrases/ approaches on the ‘pre-contemplative’ phase for co-debriefers.
    This article starts more with the ‘how’ of co-debriefing whereas i think we also need more on the ‘why’ – getting co-debriefers insightful and engaged at all.
    Generally we want to engage these folks – for their content expertise, credibility with their learners, and connections with the clinical teams – so excluding them on the basis of their lack of debriefing training or expertise is a big call.

    All that said – i also spend a lot of time in completely enjoyable co-debriefing dyads with peer colleagues and sim fellows – where i find a shared approach to structure ( we use PEARLs) is a massive enabler of complementary conversational techniques,


    And…. could it be that Catherine is a little sweet on Nimali herself….. mischievous raised eyebrows and all… sometimes those educators can be obvious to these signals……:-)

  • Daniel Lugassy (NYSIM Journal Club Group)

    Hello Simulcast
    I am writing a summary on behalf a group of faculty, fellows and residents who reviewed this article as part of our re-boot of a monthly Journal Club meeting at the New York Simulation Center for Health Sciences (NYSIM). Several of us who know this article were very excited to read this “classic” paper and those who were new to this paper found it to be very high yield.

    Our group echoed many of the previous comments already posted here, so I am going to post a summary of responses to the first and last questions you posed to us after the intro of “Explicit Thoughts.”

    What challenges do you experience co-debriefing?
    Our group collective found several of the following situations challenging when debriefing with someone else, including:
    -Co-debriefing with someone is more “senior” or “expert” to you
    -Co-debriefer has their “own agenda” that is disruptive and not in line with goals/objectives of the simulation
    -Co-debriefer with expertise “went down a rabbit hole”, too much details, too much lecture type style and again steered away from goal/objectives
    -Co-debriefer is unprepared, did not looking at faculty guide. “Does not have a clue”
    -Contradicting each other, even worse when co-debriefer undermines or insults other faculty in front of learners during debriefing —> Very dangerous for psychological safety of learners
    -Co-debriefer makes learners uncomfortable, either with constant pimping/GWIT Questions and Judgmental debriefing and you cant stop it

    Does this paper help?
    The group overwhelming felt this paper has and will aid them when planing to co-debrief. The main takeaway that may seem simple but co-debriefers NEED TO TALK to each other before AND after the debriefing. A pre-briefing between co-debriefers that includes transparency and clearly delineating roles and responsibilities can help prevent many of the above challenging situations.
    This paper helped because:
    -Formalized and Named….It provided a clear lexicon of situations almost everyone had experienced in co-debriefing/teaching. “Name it to tame it”
    -Helpful sample statements/language, such as in the section on reactive open negotiation strategies (ie. ‘‘I noticed you transitioned the discussion to communication a few moments ago….)
    **One of the only criticisms of the paper was that our group collectively wanted MORE of these “pre-made” statements to use when challenging co-debrief situations arise
    -Normalized: great to know its not just us who have been in these challenging debrief situations:)
    -Being prepared: now we will be less surprised and expect some of this difficult situations may occur in co-Debriefing
    -Suggestion of “negotiating above the table”

    Lastly the group also shared some tools/concepts for effective co-debriefing they learned over the years from CMS and other debriefing courses, other literature, personal experience and I just wanted to highlight two:
    -Two comment rule: committing to each limiting the number of comments about a topic or concept to two. This prevents excessive rumination of an idea between co-debriefers even if they are the same page and working well together. Seriously…how many can you skin a cat:)
    -Agreeing to try to use language like “Yes, AND…” instead of “Yeah, BUT..”

    A take home message from the group:
    Debriefing is HARD and it takes practice and Co-debriefing has some great advantages but is HARD too and both are improved by PRACTICE and PREPARATION.

    • Ben Symon Post author

      Danny thanks so much for sharing this and engaging NYSIM in a journal club. How did it go? I agree with the sentiments of the groups findings, although I haven’t heard of the two comment rule before! I like it. Hope you all can make it next month!

      • Daniel Lugassy

        Ben, it was great! Using the format of reading your article of the month and then discussing together worked wonderfully. We had planned for one hour and discussion was still going almost 2 hours after we started. There were excited to know that there will be an accompanying summary and podcast later and these serve as resources to follow along even in they cant make the in person JC at NYSIM.
        We will be using the same format of using Simulcast Journal Club article for the next NYSIM JC in October and I’ll post our groups comments again.

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