Exploring the Discourse of Debriefing Interactions: Areas for Improvement

Debriefing has been widely used as part of simulation-based education (SBE) to promote reflective thinking and prepare students for real clinical practice. This study examined a real debriefing transcript to identify its structure and gain insight into communication strategies used by the participants. The sample included an extended debriefing session in which a debriefer and undergraduate students, who participated in a critical care nursing simulation, engaged in a self-reflection phase. Adopting discourse analysis approaches, the analysis revealed how this interaction unfolds. The analysis also unveiled an asymmetric relationship during the debriefing that positioned the debriefer in a position of power and interactional dominance, and placed students in a passive role. Interactional features such as the use of open-ended questions, silent pauses, and informative feedback were identified as effective communication strategies to support the interaction; however, to achieve efficient self-debriefing, debriefers in this setting are encouraged to balance the use of questions to avoid restraining students from engaging and producing extended turns. Moreover, debriefers need to establish a safe environment that optimizes students’ involvement in self-reflection. This study recommends the use of other debriefing techniques to minimize the dominance of the debriefer during the interaction.


Introduction
In preparation for real-life clinical practice, nursing education programs strive to provide students with learning experience that promotes critical thinking and develops clinical decision-making skills in safe environments and without risking real patients' lives (Durham & Alden, 2008;Eyikara & Baykara, 2017).Thus, simulation training, which allows learners to participate in interactive patient care clinical scenarios, is widely used as a teaching technique in nursing curricula (Campbell & Daley, 2017;Durham & Alden, 2008;Mohammad, 2020;Omer, 2016).Debriefing, the feedback phase, is an essential cornerstone of any simulation practice.This phase is meant to promote reflective thinking and prepare students for clinical practice, that is, to cope with the high demand for health workers who are exceptionally competent and equipped with necessary skills to provide safe and quality care (World Health Organization, 2016).Accordingly, debriefing has been widely used as part of simulationbased education (SBE) (Boet et al., 2011;Decker & Dreifuerst, 2007;Decker et al., 2013;Dreifuerst, 2009;Fanning & Gaba, 2007).As defined by Boet et al. (2011), debriefing is ''the feedback process which follows the scenario and encourages the learners to reflect on their performance' ' (p. 1377).This vital process engages students in self-reflection practice that encourages them not only to analyze their actions, evaluate their clinical reasoning, question their clinical decisions, but also identify and fix any performance errors that occurred during the simulation; that is, to improve performance in future practice or real scenarios (Belote, 2015).Several debriefing techniques have been discussed in the literature (Belote, 2015), including the widely used instructor-led debriefing, which requires the presence of a trained expert who leads the debriefing and provides formative feedback, and within-team debriefing, which relies on self or peer performance assessment (Boet et al., 2011;Helal & Hafez, 2019;Oikawa et al., 2016).Regardless of what technique is used, Decker et al. (2013) outlined five essential criteria for structuring and facilitating the debriefing process: (1) the presence of a trained debriefing facilitator; (2) the performance of the debriefing in a safe and supportive environment; (3) the utilization of appropriate guidance from a facilitator who observed the simulation; (4) the use of structured framework for the debriefing session; and (5) the connection between the debriefing and the objectives and outcomes of the whole simulation session (Decker et al., 2013).
Studies on debriefings have revealed that engaging students in self-reflection enriches their knowledge, fosters their learning from hands-on experience, shapes their instinctual clinical responses, and improves their clinical judgment and reasoning (Shinnick et al., 2011;Tanner, 2006).To make this dynamic interaction effective, the quality of debriefers' observations during the simulation, their ability to give feedback, and student's conscious awareness of their own actions and their ability to reflect upon the interventions taken or not taken during the simulation are vital.Accordingly, due to the lack of analyses of authentic debriefings as many of the current investigations are descriptive (Cant & Cooper, 2011), as any other type of educational discourse, evaluating actual debriefing episodes is essential for discussing and improving this type of practice (Eggins & Slade, 2013;Grant & Jenkins, 2014).Thus, to understand how this type of interaction unfolds, this study utilizes discourse analysis (Eggins & Slade, 2013;Slade et al., 2015;Tannen et al., 2015) to examine the discourse of debriefing sessions in an educational setting.

Research Design and Participants
This qualitative study employed discourse analysis approach to explore the dynamics of student-debriefer interaction in a debriefing session.It aimed to identify the structure of the debriefing and describe the linguistic features and communication practices used during the debriefing, and their impact on the dynamics of this type of interaction (Eggins & Slade, 2013;Slade et al., 2015).
The primary data source in this study consists of onsite audio-recording of naturally occurring interactions between students and a debriefer during a debriefing session in a Nursing College (female sector), Saudi Arabia.One debriefing session was transcribed verbatim (see Appendix A for conventions and description).The participants in this session included nine Saudi female senior undergraduates, who generally fall between the ages of 21 and 24.All students were enrolled in a Critical Care nursing course and participated in a Code simulation session as a requirement for this undergraduate course.This course provides students with supervised clinical practice, such as bedside teaching, direct patient care, and scenarios analyses, among others.The participants speak Arabic as their first language, however, use English as a means of communication in both college and work.In this setting, English is the official medium of communication in health colleges and hospitals as in the Middle East (Suliman & Tadros, 2011).The other participant in this episode was a female debriefer, a non-Saudi nursing faculty who speaks English as her first language.Approval for this study was obtained from King Abdullah International Medical Research Center (KAIMRC).Informed consent which reinforces to all participants that their participation is totally voluntary and would not impact their performance evaluation or course completion, was obtained.

Results
An initial analysis of the debriefing transcript revealed that the greatest amount of discourse during the debriefing session-which is supposedly intended for selfreflective discourse by the learners-was primarily produced by the debriefer.The students' main contributions to the debriefing were to respond to the debriefer's questions.The amount of talk in this dataset was calculated by measuring the length of the debriefing episode (de la Croix & Skelton, 2009;Staples, 2015) and the length of the speaking turns in words (Clift, 2016;Sacks et al., 1978).Table 1 provides the average number of speaking turns and words spoken by the debriefer and the students during the debriefing episode in this sample.The average number of spoken words was higher (88.83%) for the debriefer than for the students.Additionally, the average number of speaking turns was higher (57.78%) for the debriefer, who produced extended turns, than for the students whose short turns varied between singleword responses and incomplete thoughts-samples of this discourse will be shared in the following section.
To further explore the debriefing interaction, the rest of this paper examines this extended debriefing session which lasted for 27 min.The debriefing began with the death of the simulated patient due to the occurrence of a major error; that is, students' inappropriate execution of a task.This error led to the faculty interjection to end the simulation and begin the debriefing phase.
Excerpt 1 illustrates the opening phase of the debriefing session.Following the performance error, the debriefer steps in to end the session (line 2) by announcing the cause of this sudden termination (''okay we ALL" just exploded from what you did'').Then, in line 21, the debriefer directly shifts to the debriefing phase, (''okay what else happened?'').In this dataset the debriefer used open-ended questions, wh-questions as an interactional feature to mark the shift from the simulation to the debriefing.The use of questions is one of the most studied initiating moves in medical discourse (Ainsworth-Vaughn, 2003;Boyd & Heritage, 2006;Husebø et al., 2013;Jones, 2013).Studies have identified this interactional feature as an effective technique not only to control and guide the discussion, but to encourage speakers to disclose information as well.
Following the opening phase, the rest of the debriefing interactions between the students and the debriefer revolved around the major errors that occurred during the simulation.In Excerpt 2, the debriefer employed the open-ended question technique to address a group of students who were observing the simulation.This move led to consecutive question-answer exchanges between the debriefer and this group of students.The students' short, incomplete thought contributions in line 23 (''the doctor''), line 29 (''the social worker''), and line 31 (''the team'') required the debriefer to support the interaction with two interactional features: (1) an additional speaking turn to fill in missing information (lines 24, 30, and 32), and (2) the use of questions (tag and/or openended questions) (e.g., ''isn't?,''''what else?'') to keep the discourse exchange open.Although the debriefer's strategy was effective at keeping the interaction going and eliciting further discourse from the students, the additional speaking turn to fill in missing information could have been substituted with open-ended follow-up questions which help students expand their thoughts, such as ''what do you mean?Can you expand on your thoughts about.?'' and ''what about the role of the doctor?How can the doctor help in this scenario?''which give students more scope to think in depth, expand and elaborate on their previous minimal turns.
In Except 3 the debriefer uses the same open-ended question technique, but this time with the use of emotional questions (Gibbs, 1988) such as in line 35 (''How did you feel about this?'') to push the debriefing interaction forward.She also directs her questioning to the code-team which was directly involved in the simulation.The type of questions used by the debriefer here represents a persistent attempt to encourage students selfreflect on their simulation experience (Decker et al., 2013).The debriefer supports this interactional move in line 36 with the use of fluency features such as silent pauses as a communication style to elicit responses (Abulebda et al., 2020;Staples, 2015).To illustrate, the 10-s pause in line 36 opened up space for a student to reflect on her role as a secondary nurse in the code-team.
The student reflected on her role in preparing medication in the presence of a pharmacist who had similar responsibilities.This reflection led to a question-and-answer sequence in which the debriefer explicitly explained the unique responsibilities of each role.The debriefer then marked the end of this case and the shift to a new one with the use of an open-ended question (''what else ladies?'')and a short pause (line 52).This phase of the debriefing interaction (Excerpts 1 and 2) was an example of an effective debriefing interaction in which the debriefer used appropriate interactional techniques to encourage student involvement, self-reflection, and at the same time halted any deterioration in the debriefing exchange.However, it is worth noting that the debriefing opening phase is essential to establish a debriefer-student bond which ensures students' psychological safety (Abulebda et al., 2020;Decker et al., 2013) and, thus, optimizes their involvement in self-reflection.Accordingly, it is vital to avoid moments of communication risk such as the sudden move to the debriefing phase as well as the use of inflammatory comments (e.g., ''You killed the patient (1) You killed yourself (3) You killed ALL" of us'') which may jeopardize the needed safe and supportive debriefing environment in which students can effectively participate in self-reflection (Decker et al., 2013).
In Excerpt 4, employing the same interactional features, the debriefer builds on the medication topic, this time directing the talk to the pharmacist (line 54).This transition is challenged by the student's inability to properly respond back to the debriefer's questions (Lines 59 and 61), which this time targeted higher ).Once the debriefer described the desired performance that students had missed at the medication stage in line 73, (''Atropine is the drug that you guys "missed''), she ends her line with a long pause, which could have been an ideal opportunity for students to step in and share their thoughts and assessment of the situation.With no response, the debriefer reflects on the desired performance of CPR, with steps emphasized using stance interactional features such as modals of necessity (e.g., ''have to,'' lines 75-79) (Staples, 2015).Necessity modals were used frequently by the debriefer mostly to suggest and list recommended best practices.
Although the simulation was done on a manikin, the debriefer reminds the students that they should immerse themselves into the procedures as if they are being performed on a real patient, ending her comment with a long pause (line 83).What the debriefer is emphasizing here has also been emphasized by Campbell and Daley (2017), who pointed out that students must feel responsibility for care in order to effectively perform their assigned roles in a simulated environment.
Although the use of interactional features such as whquestions, direct discourse, and pauses were effective techniques for eliciting information and encouraging self-reflection, it became less effective in subsequent interactions.
In Excerpt 5, lines 84 to 87, the debriefer uses the questioning technique to lay the framework for encouraging the students to evaluate their clinical decisions regarding the performance of adequate ventilations.This technique seems to work when the debriefer addressed her questions (with more other questions, lines 90-96) to a nurse, who gave minimal yet correct responses (lines 89, 91, and 97).For example, the debriefer's recast with high pitch interactional technique in line 98 (''Disconnect"'') seems to confirm the student's correct self-evaluation.However, it would have been better to supplement it with positive feedback such as ''good,'' ''great'', ''correct answer'', etc. to reassure the participant and encourage further selfreflection or reasoning (Slade et al., 2015).In line 100, the debriefer explained to the students that the patient's condition needed to be stabilized before being connected to the ventilator.We observe the use of the pitch range technique during this phase.An example of this is when the debriefer, who is most likely concentrating on the training aspect of this interaction, constantly employs a high pitch to call attention to information (e.g., ''disconnect"''), to request information (e.g., ''what did you do?"''), or to mark a shift in topic (e.g., ''what else?"'') (Mohammad, 2020;Pickering, 2001).The students, however, consistently employed a lower pitch in their responses (e.g., ''no disconnect#'').While the students' tone choice can be interpreted as a lack of confidence or interest in engaging in the debriefing session, it may also reflect a negative consequence of the use of the high pitch technique by the debriefer (e.g., lines 58-62), as it may disrupt the supportive context needed for effective debriefing (Decker et al., 2013).However, this feature -the pitch range technique-will need to be explored further to identify its impact on the debriefing interaction.The interaction in Excerpt 5 resumed with the debriefer's use of imperative form (e.g., lines 102 and 106) to highlight situational awareness and task management performance errors (e.g., the position of the nurse with respect to the simulated patient and the unattached tube).Despite the use of pauses in lines 103 to 106, this technique failed to attract any further reflection from the student or the rest of the team.The debriefer, in a manner similar to Excerpt 4, then reminds students that their performance and demonstration of the required procedures should be realistic, ending this phase with the longest pause in this episode (line 111).
In Excerpts 4 and 5, we observe an increase in the length of silent pauses by the debriefer.In the entire episode, the debriefer used the pause technique: (1) to open the floor for student reflections (e.g., ''what else ladies?,'' 5); (2) to emphasize instructions for a desired performance (e.g., ''you have to synchronize it with the ventilation,'' 10); (3) to highlight a teaching point (e.g., ''the only difference is (3) that it's not a real patient (10)''); and finally, (4) to give advice on how to avoid errors in order to enhance the students' performance during the simulation (e.g., ''you should have control over what you are doing"'' (10)).The lack of students' awareness of the purpose of the debriefer's pausing, especially if these pauses were intended to invite feedback or reflection, may negatively impact opportunities for collaborative interaction and self/team-reflection.
Although the debriefing in this setting, based on field notes, was meant to be guided by four questions shared in the simulation template (how did you feel during this situation?, how did you feel about the role assigned to you?, did you feel comfortable working as a team?, what strengths and areas of improvement were identified during this session?),Excerpt 6 reveals the overall structure of the debriefing.The debriefer first targets an incorrect performance (e.g., ''nothing" was actually done for the wound at ALL"'').By doing this, the debriefer initiates a You have to actually do it (16) Lines 112 to 120 the debriefer provides detailed instruction on how to secure the tube ''noticing'' phase, which requires clinical knowledge, experience, and/or textbook knowledge.The debriefer then breaks down the performance with the use of the interrogation and pause techniques to elicit information about the ideal/desired performance (e.g., ''what do we know about impairment injuries?'')and to encourage selfassessment (e.g., ''How do we know what to do?'').
Following the absence of, or minimal, reflection by the students, the debriefer finally provides an informative explanation of the desired performance (e.g., lines 130-140).As a result, the debriefer performs the noticing (i.e., identifying the problematic areas), analyzes and reflects on the incident, and provides the alternative best practice.Whether this structure is intended or not, the When you uh defibrillating the patient uh how do you do it?(4) Lines 192 to 211 the debriefer explains to students how to use the defibrillator students' knowledge that errors will be noticed for them and that they will eventually receive a detailed explanation of the ideal performance from the expert in the room will likely discourage any attempt to self-reflection.
The final excerpt (Excerpt 7) represents the ending phase of this interaction and reveals a significant issue that might have impacted the quality of this debriefing.As the debriefing ends, the debriefer asks a significant closed (yes/no) question ''Did you ALL" watch the simulation on blackboard?,'' line 212.This question indicates that there was some sort of preparation that the students had to do prior to the simulation session which included watching simulation-related tutorials.With no student response during the long pause after that question (line 212), the debriefer repeats the question with an amplification to indicate the availability of these tutorials on blackboard platform.She then, with a high pitch tone and imperative form, directs the students to watch the ideal simulation scenario to understand what they were expected to perform.In the closing statement, the debriefer ends the debriefing session with a remark in line 220, ''confidence is the key,'' which may indicate that appropriate preparation could have led to confident performance.

Discussion
This paper examined an actual debriefing episode which was part of clinical simulation training in a clinical course.The facilitator-student interaction during the debriefing session revealed that the traditional structure, expert-guided debriefing (Boet et al., 2011;Oikawa et al., 2016) is used in this setting.As noted in the analysis, the debriefer guided the debriefing session and provided formative feedback.Doing so, the debriefer utilized various linguistic features and communication strategies to facilitate the debriefing session.In line with previous research, these strategies included the use of open-ended questions, silent pauses, direct discourse, and informative feedback (Eggins & Slade, 2013;Slade et al., 2015).Nevertheless, to improve this type of communication, it is recommended that debriefers in this setting employ other debriefing techniques.For example, debriefers can: (1) include video-assisted reflection, which may help students notice their performance and solicit deep reasoning and self/peer-assessment (MacLean et al., 2019), thus eliciting informative reflection; (2) engage students in a selfreaction phase prior to actually analyzing their performance (Decker et al., 2013); (3) that is, to focus first on what went as desired (positive feedback can put students in an empowered position), then what needs to be improved; (4) recast improper performance in the scenario (an alternative to video playback) to allow students notice their own mistakes and improve their reflection on their performance; and (5) train students prior to the debriefings on strategies that can expedite self-reflection and help them take advantage of the techniques used during the debriefing phase.Additionally, as revealed in the analysis, the heavy reliance on the use of questions can make the interaction dominated by the debriefer creating an asymmetrical relationship between the debriefer and the students.To encourage students' full involvement and instructive self-assessment and reflection, debriefers in this setting are encouraged to balance the use of questions to avoid restraining students from engaging and producing extended turns, thereby positioning themselves in a passive role (Slade et al., 2015).Students need to be encouraged to take an active role, question their clinical decisions, and reflect on their performance as such experiences contribute to their future clinical judgment and reasoning (Boet et al., 2011;Decker & Dreifuerst, 2007;Dreifuerst, 2009).The analysis also showed that debriefers need to shed light on good performance with supportive feedback in an attempt improve students' motivation and establish rapport, which can empower students and ease any distress barriers (Slade et al., 2015).Finally, to improve the dynamics of debriefing interaction in this setting, video-facilitated reflection can be implemented to shift the interaction from expert-centered communication into collaborative communication, closing the observed distance between the debriefer and students in this setting (MacLean et al., 2019).This study has some limitations.The major limitation is that the analysis focuses on a single debriefing session, therefore, findings may not be representative or generalizable to other debriefing sessions either in this specific setting or other health educational settings.Hence, further investigations are necessary to evaluate We did that because we wanted you to kn::ow 218 before you come here actually (10) 219 Are there any questions?(6) 220 Confidence is the key (8) authentic debriefing sessions in this setting.A further limitation in this study relates to the participants involved in this debriefing session.As noted by the debriefer, an ideal simulation session requires pre-preparation from the learners, which eventually impacts the quality of simulation practice as well as debriefing interaction.Further research can investigate the impact of simulation pre-preparation on the quality of debriefing interactions.

Conclusion
Debriefing has been widely used as part of simulationbased education (SBE) to promote reflective thinking and prepare students for real clinical practice.This study showed that for this type of discourse to be effective, active participation, clear communication, and elaborate self-reflection are essential.Moreover, this study confirms that the presence of an expert during debriefing is vital.An expert ensures that a high quality of patient care is provided, validates students' clinical decision making, and optimizes students' performance by minimizing unnecessary errors.However, the dominance of the expert's presence should not override the students' presence in the debriefing interaction; that is, to promote learners' abilities to effectively analyze their own performance and practice efficient self-debriefing.

Table 1 .
The Number of Spoken Words and Speaking Turns Overall and by Participants.