The growth of simulation in EMS education has brought high fidelity mannequins, realistic patient care environments and even virtual reality into classrooms. But whether sophisticated equipment or peer-actors and task trainers are used, most learning from simulation takes place during debriefing after the scenario [1,2].
Debriefing should be a discussion about performance in a scenario, not a one-sided critique about what was good and bad. The Gather-Analyze-Summarize debriefing model is a tool to guide scenario participants to reflect on what they did, why they did it and how the experience can be applied in the future. The GAS model can be applied to any scenario, scaled to any group size, and can be used during or after scenarios [1].
Here are six tips for using the GAS model for debriefing:
1. Plan the debriefing when planning the scenario
Planning what to discuss during debriefing is just as important as planning the events during the scenario. When developing scenarios, start by identifying learning objectives and determine what acceptable performance is. Plan to take notes, use a checklist or review video to track critical points and actions in the scenario, and to focus on performance gaps during debriefing.
Decide whether the participants will be prompted during the scenario if a mistake is made or critical intervention is not performed, or if the scenario will continue regardless of what takes place until a predetermined stop point. Pausing scenarios for reflection and feedback is appropriate for formative scenarios, which are designed for teaching a new module or protocol to correct mistakes and prevent development of bad habits [3].
Summative scenarios, where participants are assessed on how well they can apply concepts and work through problems, are best run without interruption. The simulated patient would decline if critical interventions are not performed or if an error is made, and debriefing about the events only takes place after the scenario is complete.
Budgeting time for debriefing is another critical part of scenario planning. Depending on the complexity of the scenario, debriefing may take longer than running the scenario [2]. In the GAS model, plan to spend 25 percent of debriefing time in the gather phase, 50 percent for analysis and 25 percent in the summarize phase [1].
2. Set up a safe container with a pre-brief
Simulation is intimidating for participants who may feel uncomfortable performing in front of their peers, lack confidence in the topic area or fear harsh criticism [2,4]. Scenario participants who feel threatened are also more likely get defensive about their performance during debriefing, but those who feel an alliance with instructor are more likely to share thought processes behind actions and learn more from the experience [2].
Pre-briefing before the scenario allows facilitators to learn about scenario participants and for the participants to understand expectations. Start by asking participants to share about their experience as an EMS provider or student, their comfort level with the topic area of the scenario, and their experience with simulation in the past.
Set ground rules that create an environment where participants are open to learning, such as:
- The goal of simulation is not perfection, but for participants to be challenged, to make mistakes and to learn from mistakes
- Whether feedback will be given during the scenario or only afterwards
- Whether any outside resources are available during the scenario, such as calling medical control
- Whether or not the scenario will be recorded and who will see the recording
- With whom the scenario outcome will be shared
- Obtaining agreement that participants will not gossip about what happened [2, 4]
Think of facilitating a scenario as coaching a sports team during a scrimmage game. You want team members to push past their comfort levels, experiment and take risks in a setting that won’t harm patients, and the goal is for everyone to perform better on their next call. Participants will take more away from the scenario if that is communicated before you begin.
3. Gather Phase: Encourage participants to share observations and feelings
Simulation can be an emotional experience, and participants need an opportunity to release those emotions before they are able to learn from events in the scenario [1].
Start debriefing by asking participants about their initial reaction to the scenario, then guide the discussion by pointing out behaviors you observed at key points during the scenario, such as “I noticed you raised your voice when you saw that the oxygen was not turned on,” or “I noticed everyone stopped talking when the patient did not respond to naloxone,” followed by “What were you thinking when that happened?” or “Did everyone observe that event?” Use open-ended questions and active listening – ask for clarification, repeat what participants share in your own words and ask participants if they have been in a similar situation in the past [1].
After emotions have been defused, ask the team leader to review the main points in the case and seek input from team members about what happened. This allows participants with different roles in the scenario to understand the overall goals of the scenario before connecting events to learning objectives [1].
4. Analysis Phase: learn why events happened before giving feedback
After discussing feelings about what happened in the scenario, guide participants to reflect more deeply about why they acted in the way they did during the scenario, and then give feedback to compare their performance with the standard [1,2].
Facilitators need to understand what participants were thinking when they made decisions in order to give appropriate feedback. Point out observable behaviors, such as, “the patient was found in respiratory arrest and received oxygen via non-rebreather mask. What were you thinking when you chose how to deliver oxygen?”
The participant may have not have recognized that the patient was not breathing, may not have known the correct treatment for a patient in respiratory arrest, or may have misinterpreted something covered in class. Provide feedback connecting the reason for that action to the learning objectives. Point out positive events too, such as, “you promptly started CPR and defibrillated within 30 seconds of the patient losing a pulse.”
Assume that participants are making the best decisions they can based on their knowledge and experience, and ask questions about events out of curiosity, not for interrogation. Do not put scenario participants on the spot and ask them to recall facts or explain diseases, and avoid long lectures about events in the scenario; this ruins any alliance between facilitators and participants.
Limit the analysis to three to five objectives to discuss, even if there were more issues. Covering more points comes with a risk that participants will not remember any.
5. Summarize Phase: have participants share what they took away from the scenario
Wrap up the debrief by reviewing the lessons covered in the scenario and ask participants how they will apply the experience to their practice. Ask about what they felt went well during the scenario and what they would change in the future. Verify that participants understand the intended objectives, and ask participants if they have any final questions or comments [1].
6. Microdebrief during formative scenarios
The GAS model can be also be applied during formative scenarios. Direct the participant’s attention to that item, such as, “I noticed that no one is doing chest compressions right now,” or “I noticed that no one applied a capnography circuit to the ET tube.”
Then ask what participants are thinking or feeling at the moment before the pause (gather), guide them to figure out what needs to be done to improve the performance (analyze), and ask them how that will change during the rest of the scenario (summarize). Focus on a specific action and resume the scenario as quickly as possible.
Effective debriefing is essential for sustained learning from simulation scenarios. The Gather-Analyze-Summarize method is a valuable tool for guided reflection and feedback about events during simulation, and how that experience can be applied to future practice [3].
References
1. Phrapus PE, O’Donnell JM. Debriefing using a structured and supportive approach. In Levine, AI et al (eds.),The Comprehensive Textbook of Healthcare Simulation. 2013; New York: Springer Science + Business Media. DOI 10.1007/978-1-4614-5993-4_6
2. Szyld D, Rudolph JW. Debriefing with good judgment. In Levine, AI et al (eds.),The Comprehensive Textbook of Healthcare Simulation. 2013; New York: Springer Science + Business Media. DOI 10.1007/978-1-4614-5993-4_6
3. Eppich WJ, Hunt E, Duval-Arnould JM, Siddall VJ, Cheng A. Structuring feedback and debriefing to achieve mastery learning goals. Academic Medicine. 2015;90, 1501-1508. doi:10.1097/ACM.0000000000000934
4. Rudolph J, Roemer D, Simon R. Establishing a safe container for learning in simulation: The role of presimulation briefing. Simulation in Healthcare. 2014; 9:339 - 349.
