“Stimulate to Simulate Stressful Scenarios to Debrief the Debriefer…”

Hello again, apologies for the delay in posting! It took that long to think of another alliterative title…. I have a 2 yr old daughter and we were watching Monsters inc the other day. The opening sequence is….

Simulation in Disney! It got me thinking about a “train the trainers” course i had done recently. There are many out there and if you are interested in medical education, simulation or have a job where you teach ( doctors, nurses, medical students etc), then I would definitely recommend going on one. My interest are in how we can use simulation to test systems in hospital/ prehospital settings and I also wanted to have a better understanding of how to debrief someone in a more structured way.


There are numerous methods of debriefing available online, I think the one that we all have heard about is Pendleton’s guide developed in 1984. (click on the hyperlink and look at the module on feedback!)

1) Does the learner want feedback?

2) Elicit from the learner what they did well- strengths only and don’t let them stray into weaknesses.

3) Ask the observer/ group about what went well.

4) Ask the learner what didn’t go so well and what they would do differently next time.

5) Ask the group to suggest what could have been done differently.

6) Say what you think could have been done differently.

I’ve seen doctors use a form of this and calling it the “ATLS (Advanced Trauma Life Support) Sandwich”… “start with something good, then add something bad, then finish with something good”

Pendleton’s rules have some advantages: Gives the learner an opportunity to evaluate their own practice and allows the observers to build on the learners observation. It also ensures the strengths are given parity to the weaknesses.

However it can have some disadvantages: it can be difficult to separate the strengths from the weaknesses and learners can find it difficult to identify strengths.


As I said before there are many other feedback methods out there. The one that clicked with me is “PARROTS”.  It talks about “priming” the learner before the scenario.

Before the simulation begins:

1) Tell the learner what the objectives of the simulation are.

2) Ask them what they want they want to get out of it. What are their expectations. (It may be different to yours)

3) Tell them what areas of feedback are going to be given including some specific criteria. (e.g. Teamwork, leadership etc)

This seemed so simple yet I had never come across it before during my training. I used this recently with some final year medical students in a resus teaching session on basic airway management. I taught them the how to approach airway management in the unconscious patient before starting the scenario. It made a huge difference on the way the simulation went. It gave the students confidence during the simulation. Usually I would have just told them a brief outline of the scenario, “you are in resus and an unconscious patient has arrived….” and asked them to start. We can all guess how that turned out!……

Now another important lesson I learnt is to use the observers  during the simulation to help you give feedback. For example, give someone a task to specifically look at the “Teamwork” element of the scenario, or the “leadership” element. There are specific simulation criteria on these elements available online to print beforehand. This helps them stay focused during the sim and will involve them during the feedback. It also allows you to facilitate the debrief as oppose to conducting all of it.

The “PARROTS” debrief steps are:

Promote reflection: Ask “How did it feel?” “Did anything surprise or challenge you?”. You want to explore the immediate reactions from participants.

Align feedback: Signal specific objectives to give feedback on. “You wanted feedback on A,B and C etc. So lets begin with…”

Retrieve peer input: Encourage active feedback from their peers. ” Dave you looked at ‘teamwork’, can you describe some good examples of teamwork?..” 

Reveal standards: Use specific examples, “At one point you decided to go straight to theatre and not CT, can you tell me why?” “Do you know of any guidelines around this?” If you are using video then play some clips, it can really add something to the debrief. (I appreciate we don’t always have time to do this!)

Outline gaps: Identify specific areas of improvement. “You seemed unsure whether a thoracatomy needed to be perfomed in the ED? I know from personal experience when you are in the middle of a stressful situation you can forget things so don’t worry about it too much….”

Turn up strategies: Identify some individual strategies to “close the gaps”. What resources, protocols, guidelines etc available? “There are some excellent online sites regarding ED thoractomy and its indications…”

Summarise: Ask the learner “What are the main take home points for you?…” and give a summary. Being a simple soul, i try and give 3 points to remember.

Granted its difficult to remember them which is a disadvantage. I have to print off the template before hand. The key to running a successful simulation is preparation. “Sweating the Small Stuff” :o)  like ensuring all the equipment is working and available can make a huge difference.

If you are not running a simulation but assessing a trainee for a DOPS (Direct observed procedural skills) or another WBA (Work Based Assessment) try using a debrief tool that suits you. For example if a trainee asks you to observe them being a trauma team leader, instead of saying “OK off you go” and watching them, try “priming” them. “What do you want to specifically get out of it? CRM, leadership? If the patient needs intubating, use the RSI checklist. According this specific WBA the objectives are….” This also makes you look at the WBA beforehand to see what  specifically is required of the trainee to complete the assessment.

During the debrief, adapt and adopt a feedback system you like: “How did it feel?”, “I like the way you reasoned with the anaesthetist about using the RSI checklist when intubating the patient. That was great CRM.”, “You’ve told me you don’t know enough about using TEG to guide resuscitation in major haemorrhage, why don’t do have a look at this….”

I appreciate time is tight when working in a busy hospital, however if you can set aside 10-15mins after or before a shift to properly debrief, the learner will get so much more out of it.

In summary my 3 take home points are:

1) Try adopting a feedback system, there are many out there. Find one that suits you.

2) Prime the learner beforehand. It will make a huge difference.

3) Use observers to look at specific objectives to help you in the debrief and to give peer input.

Who knew Monsters inc could lead me to write about this? Hope this has been useful.

PS: There was great use of video playback during the Monsters inc simulation debrief!……



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