In this presentation Dr. Eppich outlines the PEARLS Framework, a blended approach to healthcare debriefing that reconciles multiple approaches.

1. Promoting Excellence And Reflective
Learning in Simulation (PEARLS):
A Blended Approach to Healthcare Debriefing
Walter Eppich1,2, Mark Adler1,2, Traci Robinson3,
Wendy Bissett3, James Huffman4, Kristin Fraser4, Josh Ross5,
Tobias Everett6,7, Jon Duff8, Adam Cheng3,4
1Northwestern University Feinberg School of Medicine,
2Ann & Robert H. Lurie Children’s Hospital of Chicago/USA
3KidSim Simulation Program, Alberta Children’s Hospital
4University of Calgary, Calgary/CA
5University of Wisconsin, Madison/USA
6Hospital for Sick Children, Toronto/CA
7University of Toronto, Toronto/CA
8Stollery Children’s Hospital, Edmonton/CA

2. Disclosure
• Eppich
– Center for Medical Simulation, Boston/USA
– Honoraria to teach on train-the-trainer courses with PAEDSIM e.V.
• Cheng
– Simulation Educator with Royal College of Physicians and Surgeons of
Canada
– SSH Board of Directors
• Others
– No disclosures

3. Welcome & Introductions

4. Our basic assumption
• Everyone participating in training is
intelligent, capable, does their best, and
wants to improve
Center for Medical Simulation

5. Ground rules

6. Learning objectives
After this session, you will be better able to:
1. Identify three different educational strategies used
during debriefing and when to use them
2. Discuss how learner self-assessment focused
facilitation strategies and directive feedback and
teaching fit within the PEARLS debriefing framework
3. Apply the PEARLS blended approach to debriefing
using the decision support aid and the PEARLS
debriefing tool

7. Workshop Outline
• Introductions
• PEARLS overview
• Video exercises
– Self-assessment (e.g. Plus-Delta)
– Focused facilitation (e.g. Advocacy-Inquiry)
– Directive Feedback
– Putting it all together
• Take Home Messages

8. Debriefing
• Facilitated reflection in
experiential learning1
• Involves “the active
participation of learners,
guided by a facilitator or
instructor whose primary goal
is to identify and close gaps
in knowledge and skills.”2
1Fanning and Gaba 2007
2Raemer et al. 2011

9. Debriefing
• Feedback and debriefing
an essential component of
simulation-based
education1,2
• What method of debriefing
is best?
– No head to head studies3
– No current method is ideal
1Issenberg et al. 2005
2McGaghie et al. 2010
3Raemer et al. 2011

10. What educators are doing?**
• Applying phases1
• Ask learners to self-assess2
– e.g. Plus-Delta (+/Δ)
• Facilitating discussion
– e.g. Advocacy-Inquiry3,4,5
• Provide directive feedback and teaching6
**Krogh, K, AMEE 2013
1Steinwachs 1992
2Fanning & Gaba 2007
2Sargeant et al. 2010, 2011, 2012
3,4,5Rudolph et al. 2006, 2007, 2008
6Archer 2010

11. What makes the debriefing effective?
1. Supportive environment
2. Allows for trainee reactions / emotions
3. Specific, concrete observation
4. Honest but non-threatening approach
5. Trainees shares their perspectives on events
6. Focus on improvement or sustaining
excellence
Simon et al. 2010. Cantillon & Sargent
2008 Archer 2010, Mann et al. 2011, Eva
et al. 2012, Brett-Fleegler et al. 2012,
Ahmed et al. 2012, Arora et al 2012, etc

12. PEARLS Framework

13. PEARLS – Blended Apprach Debriefing
Eppich, Cheng
What are the characteristics of these
methods, and when should they be
used?

14. Learner Self-Assessment
• Advantages
– Learner centered
– Easy to learn
– Multiple issues identified
quickly
What went well (plus)
What could be changed (delta) AND WHY?
What was easy? Challenging?

15. Learner Self-Assessment
• Disadvantages
– Easy to get off track
– Can easily miss opportunity
to discuss rationale
– Educator must tactfully
close performance gaps

16. Performance gap
Actual
performance
Desired
performance
Performance
gap
Rudolph et al 2008
Frames

17. Advocacy-Inquiry
• Promotes reflective
learning
• Allows for
understanding of
frames/rationale
• Group discussion
• Exploration of team
dynamics
Disadvantages
• Can be time consuming
• Very difficult to master
• Risk of conversation
going off-topic
Advantages

18. Directive Feedback
• Educators offers practical
solution(s) to performance
gaps
• Focused on actions
• Best for:
– Technical skills
– Knowledge gaps

19. Directive Feedback
• Advantages
– Rapidly close performance
gaps
– Where rationale evident,
discussion not required
– Time efficient

20. Directive Feedback
• Disadvantages
– Assumed rationale may be
incorrect
– No exploration of rationale
– May be taken the wrong
way if not delivered
effectively
– Teacher centered
– Limits group discussion

22. PEARLS Design process
Background
Framework Development
PEARLS Debriefing Tool
Usability Testing and
Feedback

24. PEARLS
Framework
Eppich, Cheng

25. ANALYSIS
Select method of Debriefing
How much time do you have?
ASK
Is the rationale evident?
Long Time
- Rationale
Short Time
+ Rationale
Short Time
+ / - Rationale
DESCRIPTIVE
May shorten if
students appear to
have a shared
understanding of case
Descriptive
Phase
REACTIONS
Reactions
Phase
PEARLS
Framework
Eppich, Cheng

26. Eppich, Cheng
PEARLS
Framework
Analysis

27. Were All Learning Objectives Covered? NO
RevisitLea
Performance Gaps
(+/∆ )
Close
Performance Gaps
Learner
Driven
Performance Gaps
Instructor
Driven
Close
Performance Gaps
Learner
Driven
Instructor
Driven
Close
Performance Gaps
Instructor
Driven
SUMMARY
Application / Summary
Learner Driven Instructor Driven
YES
PEARLS
Framework
Eppich, Cheng

28. PEARLS Debriefing Script (Overview)
Eppich, Cheng 2015
'
Walter'Eppich,'MD,'MEd,'Adam'Cheng,'MD'
Table 6
Setting the scene (may also occur before the first scenario debriefing, may abbreviate or omit for subsequent debriefings):
“I’ll spend aboutt XX minutes debriefing the case with you. First,I’ll be interested to hear how you felt during the scenario, second I’d like
someone to describe what the case was about to make sure we are all on the same page. Then we’ll to explore the aspects of the case you
managed effectively and those aspects you would have manage differently. I’ll be keen to hear what was going through your mind at various
points in the case. We’ll end by summarizing some take home points and identifying strategies to apply them in your work.”
PEARLS Debriefing Framework
REACTION
· “How did that feel?”
Potential follow-up questions:
· “How was that for the rest of you?”, “What were the rest of you feeling at the time?”
DESCRIPTION
· “Can someone summarize what the case was about from a medical point of view? What were the main issues you had to deal with?”
Potential follow up questions:
· “What happened next?”, “What things did you do for the patient?”
ANALYSIS
Signal the transition to the analysis of the case and frame the discussion:
· “Now that we are clear about what happened, let’s talk more about that case. There were aspects I think you managed effectively and other
areas that you might want to have done differently. I would like to explore each area with you.”
Learner Self-Assessment (e.g. Plus-Delta)
“What aspects of the case do you think you
managed well?”
“What aspects of the case would want to
change?”
Directive feedback and teaching
Provide the relevant knowledge or tips to
perform the action correctly
· I noticed you [insert performance gap
here]. Next time, you may want to …
[close gap]…because [provide rationale]
Facilitation (e.g. Advocacy-Inquiry)
· Specifically state what you would like to
talk about (“I would like to spend a few
minutes talking about XXX”)
Elicit underlying rationale for actions: see
page 2 for approach
Are there any outstanding issues we haven’t discussed yet before we start to close?
APPLICATION/SUMMARIZING
· Learner Driven: “I like to close the debriefing by having each you state one two take-aways that will help you in the future”.
· Instructor Driven: “In summary, the key learning points from this case were: …….”

29. Video Exercise 1
• Case:
– 12 month old baby
– Found at home unconscious, GCS 5
– RR 10 on arrival, Sat 92% RA, HR 50
– Presumptive diagnosis:
• Severe head injury, increased ICP

30. Objectives
• Demonstrate
– Steps of rapid sequence intubation in a
trauma patient
– Adequate c-spine immobilization
• Clear communication and teamwork
surrounding airway management
management
Walter Eppich, MD, MEd

31. Video Exercise 1
• Identify performance gaps
• Debriefing exercise
– Learner Self-Assessment
• Facilitator feedback

32. Video

33. Video Exercise 1 –
Learner Self-Assessment (Plus-Delta)
Identify Performance Gaps Close Performance Gaps
What aspects of the case do you think
you managed well?
What aspects of the case management
would you want to change AND WHY?
Close gaps through teaching and
discussion
- Instructor prompted
- Learner driven

34. Video Exercise 2
Focused Facilitation
• Watch video
• Identify performance gaps
• Debriefing exercise
– Advocacy Inquiry
• Facilitator feedback

35. Video

36. PEARLS Debriefing Script
PEARLS'Scripted'Debriefing'Tool'
'
Walter'Eppich,'MD,'MEd,'Adam'Cheng,'MD'
Table 7
Advocacy-inquiry: pairing your point of view with a question to get trainees’ perspective
ADVOCACY - INQUIRY
STEP 1:
EXPLORE
PERFORMANCE
GAPS
Observation about a
performance gap
Express your point of view about the observed
performance gap
Ask about the perspective
· I noticed that…
· I saw that…
I heard you say…
Appreciation
· I liked that….
· I thought that was interesting / fascinating…
Appreciation or concern
· I was thinking…
· That makes me think that…
· I had the impression that…
· It seemed to me that…
Concern
· I was wishing that
· I felt uncomfortable because…
· I was worried/concerned…
· How do you see it?
· I wonder what your thoughts were at
the time?
· What was going through your mind?
· How did you assess the situation?
· What were your priorities at the time?
· How did the team get organized?
· How did you decided that….
STEP 2:
UNDERSTAND
RATIONALE AND
CLOSE
PERFORMANCE
GAPS
Clarify understanding of the
trainee’s rationale for action
Explore the rationale and close the performance
gap
Help learners generalize
· So what I’m hearing is that [insert
performance gap] was related to
[insert frame here]….
· If I understand correctly, you are
saying that [insert performance
gap] was due to [insert frame
here]
Positive Performance Gap
· Identify and reinforce existing frame
through discussion
· Discuss/teach to highlight positive
performance
Negative Performance Gap
· Identify and explore new frame through
discussion
· Teach to close performance gap when
learning need is clear
· What strategies do you see going
forward that would he helpful here?
· How will this impact your performance
next time?
· How would you manage that situation
differently next time?
· How will your train of thought change
the next time you encounter a similar
situation?
Eppich, Cheng 2012

37. Video Exercise
Directive Feedback
Observed Performance Gap Close Performance Gap
I noticed…..
I observed….
I saw that….
I heard you say…
Next time, you may want to…. because…..
An alternative way to do this….because….
What I do to to prevent the patient from [insert
result here], is…. because …..
My take on the guidelines is… because…..

38. Video Exercise 3
Putting it all together
• Watch Video
• Case
– 12 month old boy
– Fever, vomiting, unwell x 3 days
– Diagnosis: Myocarditis

39. Video Exercise 3
Putting it all together
• Identify performance gaps
• Debriefing exercise
– Reactions phase
– Descriptive phase
– Analysis (1 or 2 performance gaps)
• Facilitator feedback

40. Video review

41. Video Exercise
Putting it all together
PEARLS'Scripted'Debriefing'Tool'
'
Walter'Eppich,'MD,'MEd,'Adam'Cheng,'MD'
Table 6
Setting the scene (may also occur before the first scenario debriefing, may abbreviate or omit for subsequent debriefings):
“I’ll spend aboutt XX minutes debriefing the case with you. First,I’ll be interested to hear how you felt during the scenario, second I’d like
someone to describe what the case was about to make sure we are all on the same page. Then we’ll to explore the aspects of the case you
managed effectively and those aspects you would have manage differently. I’ll be keen to hear what was going through your mind at various
points in the case. We’ll end by summarizing some take home points and identifying strategies to apply them in your work.”
PEARLS Debriefing Framework
REACTION
· “How did that feel?”
Potential follow-up questions:
· “How was that for the rest of you?”, “What were the rest of you feeling at the time?”
DESCRIPTION
· “Can someone summarize what the case was about from a medical point of view? What were the main issues you had to deal with?”
Potential follow up questions:
· “What happened next?”, “What things did you do for the patient?”
ANALYSIS
Signal the transition to the analysis of the case and frame the discussion:
· “Now that we are clear about what happened, let’s talk more about that case. There were aspects I think you managed effectively and other
areas that you might want to have done differently. I would like to explore each area with you.”
Learner Self-Assessment (e.g. Plus-Delta)
“What aspects of the case do you think you
managed well?”
“What aspects of the case would want to
change?”
Directive feedback and teaching
Provide the relevant knowledge or tips to
perform the action correctly
· I noticed you [insert performance gap
here]. Next time, you may want to …
[close gap]…because [provide rationale]
Facilitation (e.g. Advocacy-Inquiry)
· Specifically state what you would like to
talk about (“I would like to spend a few
minutes talking about XXX”)
Elicit underlying rationale for actions: see
page 2 for approach
Are there any outstanding issues we haven’t discussed yet before we start to close?
APPLICATION/SUMMARIZING
· Learner Driven: “I like to close the debriefing by having each you state one two take-aways that will help you in the future”.
· Instructor Driven: “In summary, the key learning points from this case were: …….”

42. PEARLS
• Provides a framework for context-specific
application of commonly used approaches to
debriefing
• The PEARLS scripted debriefing tool can
serve as an adjunct in faculty development
initiatives
• Future work will determine the extent to which
PEARLS promotes various aspects of
debriefing expertise

43. Acknowledgements
• Vincent Grant, Traci Robinson, Helen Catena, Wendy
Bissett, Kristin Fraser, Gord McNeil (KidSim Team)
• Nicola Robertson (PEARLS flow diagram)
• Mark Adler (Northwestern University)
• Jenny Rudolph (Center for Medical Simulation)
• EXPRESS Collaborative
• Royal College of Physicians and Surgeons of
Canada (SET team) and Robert Simon

44. Questions?
Walter Eppich, MD, MEd
w-eppich@northwestern.edu
Adam Cheng, MD
chenger@me.com