It is widely accepted that the main opportunity for long-lasting and deep learning of NTS takes place during debriefing after simulation [
40]. A structured debriefing session with a skilled facilitator is thought to be vital for the acquisition of NTS, as it encourages self-reflection [
10,
35]. Debriefing after real events is also beneficial but should be structured differently [
41]. The specific elements of debriefing required for improvement in NTS are not clearly defined in healthcare, and the specific skills needed for effective debriefing after simulation for NTS training can be unclear when both TS and NTS training are reviewed together. Most current studies on debriefing are limited in application due to bias and lack of generalisability; however, advice on a more systematic and standardised approach to the debrief session is needed to ensure all participants in NTS courses benefit consistently from training [
40,
42].
There are three distinct debriefing categories (Table
2): facilitator-guided post-event debriefing, self-guided post-event debriefing, and facilitator-guided within-event debriefing, e.g. freeze frames [
43]. Generally, debriefing should be as long as the simulation itself, and there should be a briefing to let participants know what to expect [
40]. Frameworks for debriefing conversations can be found summarised in the review by Sawyer et al. [
43] but more research is needed to determine any concrete benefit from using one model over another: it is likely that any model can be effective, with the act of debriefing being the important part. It is also necessary to account for the simulations’ context and what the debriefer feels most confident with when deciding on the model [
43].
Table 2
Debriefing styles
Instructor-led debriefing | Current ‘gold standard’ |
Resource intensive (requires skilled facilitator) |
Can include other techniques |
Self-debriefing | More cost effective than instructor-led debriefing |
Benefits more experienced trainees |
Video recording review | Adjunct to other methods |
Lack of evidence supporting efficacy |
Eye tracking technology | Improves patient safety tasks where visual cues must be recognised, e.g. checking patient’s wristband |
Re-do stations | Face validity—found useful by students |
More evidence required |
Freeze frames | Promote deliberate practice |
Adjunct to post-event debriefing only |
Team debriefing | Potentially beneficial, more research needed to compare to individual debriefing |
Having a script or aid can help the debriefer to deliver a higher quality session by improving team leader performance; in a study by Jaye et al., a standardised structure (‘The Diamond’) was put forward to refocus debriefing on NTS rather than TS, as well as make sure the experiences between participants are equal [
40,
44]. ‘The Diamond’ is a two-sided prompt sheet: the first side contains the scaffolding, with a series of specifically constructed questions for each phase of the debrief; the second lays out the theory behind the questions and the process. With this the variation in what is expected from debriefing can be addressed and standardised [
44]. Assessment scales like NoTSS are also useful aids, either as an adjunct to discussion or self-reflection, giving the participant objective feedback to reflect on [
38].
Debriefing styles and techniques
It is thought that having a skilled debriefer is important to the concept, but recent studies show that this might not be the case, provided that there is a form of educational process post-simulation [
40]. Self-debriefing (e.g. reviewing a video of oneself with an assessment scale like NoTSS) has been shown to be effective in learning CRM, and it was found to be similarly effective to traditional instructor debriefing in other simulations [
31]. This is important, as it can be expensive to train and hire senior individuals to these roles which impact the feasibility of simulation sessions and curricula [
40]. Self-assessment has also been shown to create more goals for learning, which are then more likely to be carried out by the individual [
45]. Self-debriefing is more cost effective than instructor debriefing, however, with a higher budget, instructor debriefing is preferred [
31]. For more experienced learners, there is less reliance on an instructor and self-assessment is more cost effective, as well as allowing participants to control the pace of debriefing and the opportunity for review of self-perceived weaknesses [
43,
46].
Often video recording is used in debriefing; however, recent studies have failed to find any additional benefit from using this technique [
40,
47]. It may even distract participants from focusing on the learning objectives, but current research is not robust enough to discount it [
46]. Eye tracking technology is an innovative method to provide participants with feedback. It significantly improves certain practices compared to verbal feedback, but other behaviours, such as decision making, are unaffected [
48]. Alternatives to traditional instructor debriefing include use of self-video review, multimedia debriefing, and within-team debriefing [
31]. Re-do stations have also been found useful by students as learning and debriefing experience, and those who had a staff member present found it more useful [
49].
Freeze frames are a form of facilitator-guided within-event debriefing [
13]. This is described as ‘stop action’ debriefing—participants can be stopped when an error occurs and receive corrective feedback before trying again. This promotes deliberate practice. However, within-event feedback alone has been found to be inferior to post-event feedback; thus, post-event debriefing should always accompany this method [
43].
A final consideration is whether debriefing should be just for the individual or within their team. In a study by Martin et al. [
30], half of each group were active participants in a case while the other half observed, and both participants and observers were invited to take part in the debriefing sessions. Participants found this to be a safe and positive educational experience [
30]. In another study, CRM scenarios were followed by an instructor facilitated debriefing, with both teams involved in each other’s debriefing [
23]. Both group and individual methods are able to adequately facilitate learning; thus, the method used should be decided based on logistical considerations and preference of the examiner.