Monday, 30 September 2013

It's all about me, me, me: the problem with advocacy-inquiry in debriefing

The importance of the debrief

It is safe to say that those of us involved in simulation believe that the debrief is a very important part of the learning experience. Many of us (1) would say it was the most important part. A slide taken from the SCSC's faculty development (train the trainers) course helps us see why (Figure 1).

Fig. 1: Scenario and Debrief mapped onto Kolb's learning cycle
When we map the simulation activity onto Kolb's learning cycle, we can see that three-quarters of the process is supposed to occur during the debrief. The debrief is important therefore because much of the learning is supposed to take place during this period.

In 2007, Fanning and Gaba wrote an article entitled "The Role of Debriefing in Simulation-Based Learning". They explain how adult learners do not find "linear teaching models" (i.e. didactic teaching) very effective and instead benefit from active participation (i.e. experiential learning as shown in Kolb's learning cycle above). The role of the teacher is to facilitate the learners' progress around the cycle (hence "facilitator") through a debrief of the events which occurred in the simulated scenario. This role is an important one, as Fanning and Gaba state:
"Data from surveys of participants indicates that the perceived skills of the debriefer have the highest independent correlation to the perceived overall quality of the simulation experience." (2, p.118)
Dismukes and Smith identify three levels of facilitation (3):

  1. High level facilitation: participants more or less debrief themselves
  2. Intermediate level facilitation: somewhere between high and low
  3. Low level facilitation: facilitator directs the entire debrief

Fanning and Gaba state that we should use the highest level possible and, in their paper, go on to list some of the debriefing styles (e.g. funnelling, framing) and techniques (e.g. plus-delta, target-focused) which are used.

Debriefing with good judgment (Advocacy-inquiry)

In conversations with some facilitators at simulation-focused conferences I have been struck by their belief that "debriefing with good judgment" is the "one, true" debriefing style. After all, who does not want to debrief with good judgment?
In their two (similar) papers Rudolph et al discuss the theory and practice of debriefing with good judgment (4,5). Drawing on "a 35-year research program in the behavioral sciences on how to improve professional effectiveness through 'reflective practice'" they cite three elements in their approach:

  1. Uncovering the participant's knowledge, assumptions and feelings (internal frames) allows the facilitator to "reframe" and improve future actions and behaviour
  2. The facilitator has a stance of "genuine curiosity" about the participant's internal frames
  3. The facilitator uses the "advocacy-inquiry" conversational technique to bring his/her judgment and the participant's frames to light.
The first 2 elements are not controversial, but the third gives me some concern. Rudolph et al define advocacy as:
"A type of speech that includes an objective observation about and subjective judgment of the trainees’ actions" (4, p.49)
To illustrate what they mean, they provide the following worked example:
I have highlighted the problem (as I see it) with the worked example below:

It's "me, me, me" and then "I, I, I". For a facilitated debrief there seems far too much focus on the facilitator. Here's my alternative to the above debrief:

Debriefer: So, how was that?
A group member: I was a bit confused by what was happening.
Debriefer: Really? In what way?
A group member: I wasn't sure who was in charge or what I was supposed to do.
Debriefer: Okay, did anybody else feel that way?
Group: Several members agree.
Debriefer: Did the confusion have any effect on how you dealt with the patient?
etc. etc.

The above is still too facilitator-driven but at least removes the facilitator as the pivot around which the conversation flows. The advocacy-inquiry technique seems to be at best an intermediate-level facilitation and at worst a low-level facilitation where the participants rely on the facilitator to discuss what he/she thought were the important points.

Should we get rid of "debriefing with good judgment"? No. Much of what Rudolph et al discuss is valid. They are correct to say that there is no "non-judgmental" debriefing. Being "genuinely curious"is also extremely important. However, I would argue that one can be genuinely curious without focusing the conversation on the facilitator.

Is there a place for "advocacy-inquiry"? Yes. Fanning and Gaba state "the debriefing techniques employed need to take individual learning styles into consideration" (2, p.117) High-level facilitation should be used whenever possible, then perhaps stepping down to advocacy-inquiry if the participants need more direction.

In their paper, Rudolph et al follow the debriefer/trainees conversation above with the debriefer saying:

I think that question needs to come much earlier.

1) Issenberg SB, McGaghie WC, Petrusa ER, et al: Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher 2005;27:10–28.
2) Fanning RM and Gaba DM: The role of debriefing in simulation‐based learning. Simulation in Healthcare 2007;2(2):115-125. (Article available for free here.)
3) Dismukes R, Smith G: Facilitation and debriefing in aviation training and operations. Aldershot; UK: Ashgate, 2000
4) Rudolph JW, Simon R, Dufresne R, et al: There’s no such thing as “Nonjudgmental” debriefing: A theory and method for debriefing with good judgment. Simul Healthcare 2006;1:49–55.
5) Rudolph JW, Simon R, Rivard P, et al: Debriefing with Good Judgment: Combining Rigorous Feedback with Genuine Inquiry. Anesthiol Clin 2007;25:361-376. (Article available for free here.)

Sunday, 1 September 2013

A train in Spain

On the 25th July 2013 a train travelling from Madrid to Ferrol derailed near Santiago de Compostela. Out of 218 passengers, 79 died. A BBC report quotes the president of the railway firm:
The train had passed an inspection that same morning. Those trains are inspected every 7500km... Its maintenance record was perfect.

One of the train drivers, according to the same BBC report, told the control room that he took the bend at 190km/h; the bend's speed limit is 80km/h. He is also reported to have kept repeating "We're human, we're human." The train was running five minutes late.

A later BBC report explores the safety systems in place on trains; the European Train Control System (ETCS) which can prevent speeding and the more basic ASFA (Anuncio de Senales y Frenado Automatico) which warns the drivers when the speed limit is exceeded but cannot stop speeding. The track where the train derailed only had the ASFA system in use. The train driver received 3 audible warnings to reduce speed, the last warning was 250m (or 4.6 seconds) before derailment. The BBC report also quotes a Spanish journalist who says that there had been concerns about this section of track since it opened, as it required the driver to reduce the train's speed from 200km/h to 80km/h "in just a matter of seconds". According to unnamed officials, the bend does not need additional safety measures "because of the proximity of a major urban center, which requires that drivers slow down trains regardless." Writing in the Guardian, Miguel-Anxo Murado tells us that:
There were arguments for having that section of the route remade completely, but Galicia's particular land tenure regime makes expropriations an administrative nightmare. So the bend was left as it was, and speed was limited there to 80km/h

On the 27th July the train driver is discharged from hospital and taken to a police station for questioning. The Interior Minister accuses him of reckless manslaughter. The driver has 30 years experience, became a fully qualified driver in 2003 and had been driving on that route for over a year.

On the 31st July we learn that the driver was on the phone to train company staff and/or the train's ticket inspector at the time of the crash. He would normally start braking 4km before the bend (at 200km/hr he has approximately 72 seconds to decrease his speed to 80km/hr).

The Guardian provides us with additional information:
Renfe is among the firms bidding for a €13bn contract to build a high-speed rail link in Brazil. The terms of the tender reportedly exclude firms involved in the running of high-speed train systems where an accident has taken place in the preceding five years.
In the latest BBC report dealing with the crash, the Public Works Minister is quoted as saying: "Everything is under review, everything is subject to proposals for improvements". There is discussion of beacons on sections of track which require rapid braking, the use of satellite technology and a review of the physical and psychological requirements of train drivers.

The train driver has been charged with involuntary homicide due to "professional recklessness".

The aftermath of this train disaster followed the same course as that of the sinking of the Costa Concordia: initial focus on the “sharp end” of the captain/driver, with immediate denials from the corporate offices of any wrong-doing or failure on their part. Then, once more information comes to light, there is an appreciation that perhaps there were other problems contributing to the sinking or crash.

Instead of an immediate denial of culpability, it would be refreshing if the president or CEO of a company would instead express sorrow at the loss of life and regret at the injuries, coupled with a promise to explore all factors leading up to the event. It is almost inevitable that any such large-scale disaster will have a number of causes and missed opportunities for prevention. However, in a world where such sentiments would affect stockmarkets and bids for contracts, this may remain wishful thinking.