The Needle Tip:

Trauma Simulation Training: Coaching the Coaches

Richard A. Falcone, Jr, MD, MPH, FACS

Cincinnati Children's Hospital Medical Center

Trauma is a team sport and great teams require both practice and great coaches to succeed. Team-based simulation training and review of videotaped resuscitations are two key methods to practice and review-team care that can lead to significant improvements in team performance, and as a result, improvements in patient outcomes, safety, and efficiency. Simulation and video review of trauma resuscitations have resulted in the identification of latent safety threats before they reach a patient, improved compliance with ATLS protocols, decreased missed injuries, clarification of roles, testing of new protocols, and many other positive outcomes that benefit adult and pediatric trauma patients. There are many reasons this type of training and evaluation works, but a key element is the coach, or the facilitator, of the debrief.

What is debriefing?

Debriefing is a form of “reflective practice.” In the process of continuous learning, debriefing provides a means of reflecting on action previously taken, and it is key to experiential learning. A key understanding is that experience alone does not lead to learning, whereas deliberate reflection combined with that experience is crucial.

The coach or facilitator is a crucial element in the debriefing process. As in any area of education or coaching, though, there are good and bad coaches. A “bad” coach can create an uncomfortable environment for the learner and remove value from the experience. Sometimes as little as one bad experience with a facilitator can lead to the downfall of a simulation training or videotape review program resulting in the loss of training that could have had incredible potential value for a trauma program.

So how does one become a good coach or facilitator?

Like most things, great coaching comes from a combination of training, practice, mentorship, and an appropriate degree of emotional intelligence. Not every great player has the aptitude or desire to be a great coach. In general there are three debriefing methods: (1) facilitator-guided post-event debriefing, (2) self-guided post-event debriefing, and (3) facilitator-guided within event debriefing.

Facilitator-guided post-event debriefing is the most common and most widely studied method, and it will be the focus of the short description below on how to debrief.

Facilitator-Guided Post-Event Debriefing

In general, the post-event debrief should follow a structure that includes guiding the conversation from a beginning, through an examination of events, and then to a summation of learning points relevant to clinical practice. The facilitator should serve as the guide for the conversation, and they should also have appropriate expertise on the content in order to help facilitate the learning of key learning objectives within each simulation or video reviewed. In our experience at Cincinnati Children’s, it is has been incredibly helpful to have a mixed facilitator group—including a surgeon, an emergency medicine physician, and a trauma nurse educator—that can offer varied and complimentary input during the debrief.

The coach or facilitator should utilize a structured debrief method. There are several methods described in the literature, and the type utilized will ultimately depend on the specific type of training being presented and the skills of the facilitator. There are key elements, however, that should be consistent for all debriefs. The coach should first create a safe learning environment and set ground rules. This should make it clear that the discussion during the debrief will be confidential, that the focus will be on the group and on quality improvement, and that the discussion will not focused on the critique of individual knowledge. In addition, it is helpful to assure participants that, as a team, they will have the knowledge base to get through the simulated scenario, and that the focus of the learning will be around how they work as a team. These clearly stated intentions and boundaries will further reinforce the safe learning environment and can reduce the stress or anxiety levels some participants may be feeling. In fact, this discussion should happen before the first simulated scenario begins to allow participants to feel comfortable and free to learn and share.

After the simulated scenario is complete, it is often useful to give the team a brief moment to react to the emotional stress of the scenario. In our experience, this can often be a very organic and spontaneous process that occurs as our teams move from the simulation room to our debrief room; we simply listen as the team members talk to each other about the scenario and share their experience.

Next, you want to establish a shared mental model. This can be accomplished by asking an open-ended question such as “So who can tell me about the patient?” This should be an opportunity for a member to essentially give a “report”: what was the mechanism, what did they do, what injuries do they think the patient had, and so on. It’s important to note that this should not be a discussion of what went wrong or a critique of the performance. Once one member shares, the facilitator should elicit input from other team members as to things that might have been missed in the report and/or whether the entire team felt they understood this during the simulation.

Next, it is useful to allow the team to share what went well during the scenario. By allowing the team to first discuss what went well, you further reinforce the safe learning environment and allow the team to then move into the more challenging discussion of what they could have done better. After discussing what went well, we generally move to “What opportunities were there?” Depending on the team’s responses, it can be very useful to break this discussion down into specific “buckets” such as: teamwork/communication, safety, equipment, resources, and knowledge.

It should be clear, based on the above, that the facilitator will not only need to understand the key learning objectives for each simulated scenario, and be sure to, and be able to, guide the team to these objectives and explicitly summarize them.

There are some specific tools a good coach or facilitator can use during a debrief, and they should be both utilized and practiced by a good coach: First, ask open-ended questions and avoid simple yes/no questions during the debrief. Next, be comfortable with silence: the coach should allow the team time to process what they just experienced before they are asked to respond, and he or she should allow for some brief moments of silence after asking for feedback. A good facilitator should also allow the learners to provide self-assessment, rather than tell them how they performed, by using questions like “What went well?” or “What could be changed?”

Another tool a coach can use is advocacy inquiry. Advocacy inquiry allows the facilitator to share their observations of an action (advocates) and then asks the learners about their thoughts or mindset at the time of the action (inquiry). Here is an example of this would look like: “I noticed the team struggling to get peripheral IV access on this young child, and I was concerned that we were not able to resuscitate this child in shock. What was going through the team’s mind at this point, and what else might you have done?” Another tool is the use of circular questions. Circular questions involve asking one team member to describe the actions/interactions of two other team members, giving an outsider’s perspective. An additional tool a facilitator can use is video review of the simulation. This can be useful when reviewing specific objective events, but complete review of the entire video has not been demonstrated to be particularly useful during a debrief. When it comes to real life resuscitations however, with a good coach or facilitator, the use of video review combined with debriefing can improve the quality of team performance and be an invaluable training tool..

In conclusion, team-based simulation training to improve trauma team performance can be an invaluable tool, but to be successful, the coach needs to be trained to ensure a safe and valuable learning experience. Just as it’s true for a team of athletes—star players, great facilities, and great equipment do not always result in a championship. The team needs a great coach to help pull all the pieces together. Our patients deserve great coaches and players!

Selected References

• Sawyer T, Eppich W, Brett-Fleegler M, Grant V, Cheng A. More Than One Way to Debrief: A Critical Review of Healthcare Simulation Debriefing Methods. Sim Healthcare, 2016; 11: 209–217.
• Eppich W, Cheng A. Promoting Excellence and Reflective Learning in Simulation (PEARLS): Development and Rationale for a Blended Approach to Health Care Simulation Debriefing. Sim Healthcare, 10:106–115, 2015.
• Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In Situ Simulation: Detection of Safety Threats and Teamwork Training in a High-Risk Emergency Department. BMJ Qual Saf. 2013 Jun; 22(6):468–77.
• Falcone RA Jr, Daugherty M, Schweer L, Patterson M, Brown RL, Garcia VF. Multidisciplinary Pediatric Trauma Team Training Using High-Fidelity Trauma Simulation. J Pediatric Surg. 2008 Jun; 43(6):1065–71.
• Parsons SE, Carter EA, Waterhouse LJ, Fritzeen J, Kelleher DC, O'Connell KJ, Sarcevic A, Baker KM, Nelson E, Werner NE, Boehm-Davis DA, Burd RS. Improving ATLS Performance in Simulated Pediatric Trauma Resuscitation Using a Checklist. Ann Surg. 2014 Apr; 259(4):807–13.