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.)


  1. Debriefer: So, how was that?

    a good open question to what the answer can be: good! And from here I see two problems (or more) first, I really disagree (but I can old it in but here the rest of the groupe cant. And then we have a discussion that is hard to facilitat). Second, the first comment is spoken by the person who has no problem speaking up in a groupe. In my experience (8 years of debriefing) this some times makes for a one sided groupe discussion where I try to involve the hole groupe but it feels lika I´m climbing a hill. In short Fanning and Gaba state said it best "the debriefing techniques employed need to take individual learning styles into consideration" but I do disagree with your conclusion that AI would mean "stepping down" the ladder of fantastic debriefing. I find it to be a key factor in making fantastic debriefings.

    Kind regards/ a debriefing junkie from Sweden (H.Dahlquist)

  2. I think that "How was that"
    Can come across as an assessment i.e.. was that good or bad, what was it out of ten etc
    I try to open with "how do you feel"
    Regarding AI: it has to be you who has made the observation, its really the "why you're interested in that bit" bit that you need to get right
    Like it
    Many ways to skin a cat