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Abstract

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.

Keywords

debriefing simulation-based learning nursing education student-debriefer interaction discourse analysis

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 simulation-based 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.

Material and Methods

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 self-reflective 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 single-word responses and incomplete thoughts—samples of this discourse will be shared in the following section.

Table 1.

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

	Overall	By debriefer (%)	By students (%)
No. of words	2,622	2329 (88.83)	293 (11.17)
No. of turns	90	52 (57.78)	38 (42.23)

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.

Excerpt 1.
Line	Speaker	Text
1	Nurse	okay, all clear↓ [nurse administering cardioversion]
2	Debriefer	okay we’re ALL↑ just exploded from what you did (4)
3		because you just shot your patient with oxygen,
4		so we all just exploded (3) so you killed ALL↑ of us now
5		<Laugh> [Nurses outburst laughing]
6		You killed the patient (1) You killed yourself (3) You killed ALL↑ of us
7	Nurse	So we should remove the [
8	Debriefer	of course yes↑ .. because
9		this is it. we all are dead (4)
10		<laugh> [all nurses laugh]
11		We all are dead unfortunately because you just caused an explosion
12		When you shock a patient, you have to remove the↑ oxygen
13		This is a critical <inaudible> so we end up that we all exploded
14		So, not only the patient is dead, but we’re also dead now (5)
15	Nurse	sorry↓
16	Debriefer	Okay ladies. This is something that is really critical
17		you can’t uhm ignore it because this is one of
18		the important things when you’re shocking the patient
19		we said uh Oxygen↑ should be taken away
20		because it fuels it it causes an explosion and that’s it (5) uhm (1)
21		okay what else happened?↑

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 open-ended 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.

Excerpt 2.
Line	Speaker	Text
22	Debriefer	You guys were watching . what else? [addresses a group of nurses]
23	Nurse	The doctor [soft talk]
24	Debriefer	The doctor↑ was given rights orders YES↑what else?
25		You have to do it in the code blue form, isn’t it?
26		Where is the code blue form?
27	Nurse	<Laughs> I don’t know
28	Debriefer	What else?
29	Nurse	The social worker↓
30	Debriefer	The social worker was helping the situation with the patient, what else?
31	Nurse	The team↓
32	Debriefer	So the team is trying to work together
33		Everyone in the team is trying to do what she was assigned to do

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 self-reflect 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).

Excerpt 3.
Line	Speaker	Text
34	Debriefer	What about you guys? [addressing the code-team]
35		How did you feel about this?
36		(10)
37	Nurse	Because I am the secondary nurse, uh when I prepare the medication,
38		there is also a pharmacist
39	Debriefer	The pharmacist is supposed to prepare the medication and give it to
40		the primary nurse to administer, you don’t have any role in this
41	Nurse	So I don’t prepare any med .. medication?↓
42	Debriefer	The pharmacist↑ is here specifically for the medication
43		YOU↑ help her with putting up the
44		IV LINE↑ <inaudible> uh so your role is actually assisting her,
45		but the medication is strictly with the pharmacist,
46		the pharmacist will prepare uh UNDER↑ the instruction of course of
47		the doctor and the primary nurse administer it
48	Nurse	So the secondary uh just uh for the IV line?
49	Debriefer	HELPING↑ with
50		anything that needs to be done okay?↑ but not medication
51		It is the pharmacist is supposed to prepare the medication
52		Uh what else ladies?↑ (6)

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 order clinical judgment: the student’s evaluation of her own clinical performance during the simulation (line 56, “What medication did you give?”), and her ability to foresee the recommended best practice (Lines 58 and 60, “What should you have given as well?” and “What could have also been added on?,” respectively). With no response to the debriefer’s elaborate attempt to help the student identify what other medication had to be given based on the patient’s condition, we see the debriefer provide detailed informative feedback (lines 62–72). 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.

Excerpt 4.
Line	Speaker	Text
53		You defined the roles [addressing a nurse]
54		Who’s the pharmacist?
55	Nurse	Me
56	Debriefer	What medication did you give?
57	Nurse	<inaudible>
58	Debriefer	- Only↑What should you have given as well?
59	Nurse	I don’t know . Atropine↓
60	Debriefer	No↑ I am asking what could have been also added on?
61	Nurse	Um maybe↓(2)
62	Debriefer	The patient has been <inaudible>
63		You don’t have any blood pressure, isn’t it? (3)
64		As an emergency drug. (2)
Lines 65 to 72 the debriefer provides hints and justification for the medication needed at this phase
73		Atropine is the drug that you guys ↑missed (10)
74		Also↑ uh the CPR (1) remember when you were giving the
75		simulation you have to give it as if you are doing <inaudible>
76		so everything has to be the depth <inaudible> the intonation,
77		you have to count (4)
78		you have to synchronize it with the ventilation (10)
79		you have to wait the chest to record, isn’t it?↑
80	Nurse	Aha
81	Debriefer	So it it (2) it is no not different just because this is a mannequin
82		It has to be exactly the same (3) the only difference is
83		that it’s not a real patient (10)

Although the use of interactional features such as wh- questions, 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 self-reflection 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.

Excerpt 5.
Line	Speaker	Text
84	Debriefer	What about uh the airway? (4)
85		You intubated the patient but↑(2)
86		At this point would you want to connect your patient to the
87		ventilator? (8) Because that wasn’t order
88		It wasn’t given isn’t? [debriefer directs her question to a nurse]
89	Nurse	Yes
90	Debriefer	At WHAT↑ point did you connect the patient to ventilator?
91	Nurse	After ↓
92	Debriefer	But you do it <inaudible> how you can achieve that if you
93		<inaudible> on the ventilator? how can you achieve that ratio? (6)
94		If you connect your patient uh to the ventilator
95		<inaudible> to this rhythm and we need to do CPR
96		What did you do?↑ Give the patient to the ventilator?↑
97	Nurse	No disconnect↓
98	Debriefer	Disconnect↑
99		so in this case you will not connect the patient to the ventilator
100		unless the patient is stable … the ventilator comes later on (5)
101		What about uh the airway inconsideration to your position? (4)
102		Look at your patient↑ [Debriefer directs her talk to a nurse]
103		the patient is SO↑ far down and look where you are↑(6)
104		The head of the bed should be up (4)
105		You should have control over what you are doing↑(10)
106		Positioning of the tube look↑ at your tube (6)
107		This thing about imaginary things going on
108		uh nothing is imagination here
109		If it’s not .. if you don’t do it .. it means it’s not done you cannot
110		document it it’s done
111		You have to actually do it (16)
Lines 112 to 120 the debriefer provides detailed instruction on how to secure the tube

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 “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 self-assessment (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 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.

Excerpt 6.
Line	Speaker	Text
121	Debriefer	What about the wound?↑ You still have the wound isn’t? (4)
122		That was the reason why the patient got into this situation
123		Nothing↑ was actually done for the wound at ALL↑
124		It was an impairment fracture (8)
125		An impairment fracture uh what do we know
126		about impairment injuries? (6)
127	Nurse	penetrating↓ <inaudible whisper>
128	Debriefer	Yeah ↑it was a penetrating injury
129		BUT↑what do you know about it? (12)
130		You have to control bleeding
131		you have to stabilize whatever is the object
132		So that he doesn’t move because it can cause more injury
133		But the priority is to control the bleeding
134		and to immobilize . that log (6)
135		Because no matter what you do if the patient
136		was bleeding if the patient was going to have
137		a Hypovolemic shock (3) actually I think the patient is
138		already having a hypovolemic shock
139		that’s the reason you had this situation (5)
140		It is always about controlling what the primary problem is (7)
Lines 141 to 163 the debriefer elaborates on simulated patient’s condition
164		Because you want to uh . what about the vital signs? (10)
165		How do we know what to do?
166		What is our guidance in terms of circulation? (8)
167		We have probably secondary reassessment
168		But what information do we need?
169		so we know how we can play around with fluids, isn’t? (9)
170	Nurse	pressure↓
171	Debriefer	Blood pressure ↑(2) you didn’t have pressure you need your map
172		You asked that once, isn’t it?
173		What was the blood pressure?↑ [debriefer directs talk to a nurse]
174	Nurse	low↓
175	Debriefer	Yeah it was already low (10)
176		Uh (2) defibrillation
177		The first line management is defibrillation
178		how do we defibrillate the patient? (6)
179		What’s the first thing you need to know about uh
180		this intervention? (3)
181	Nurse	Pulse [
182	Debriefer	The↑ patient doesn’t have a pulse (2)
183		so, if the patient has a cardiac problem (3) We↑
184		don’t have this information as yet
185		Is this a monophasic or biphasic defibrillator? (4)
186		Your task (2)
187		You need to know that↑ this is a (biphasic) defibrillator
188		And you know that this is a biphasic defibrillator, isn’t? (3)
189		These are all↑ small things,
190		but these are the things that are actually important
191		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

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.

Excerpt 7.
Line	Speaker	Text
212	Debriefer	Did you ALL↑ watch the simulation on blackboard? (12)
213		Did you see it? (7)
214		It is there for a long time now (5) with ALL↑ other videos
215		If you want to know what happens in managing this patient
216		GO↑ watch the video↑
217		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)

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 self-reaction 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 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 simulation-based 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.

Footnotes

Appendix

Appendix A

Glossary of Transcription Conventions.

Convention	Description
.	A period indicates a brief pause accompanied by an utterance final (Falling intonation contour; not used in a syntactic sense to indicate complete sentences)
…	Ellipses indicate a pause 2 to 3 s
::	Colons indicate prolongation of the immediately prior sound. The longer the colon row, the longer the prolongation
-	A dash indicates a sharp cut-off
(1)	A pause in number of seconds
[	A left bracket indicates the point of overlap onset
]	A right bracket indicates the point at which two overlapping utterances end
< >	Angle brackets indicate contextual information (e.g., <names>) or non-speech events (e.g., <laugh>)
WORD	Upper case indicates especially loud sounds relative to the surrounding talk
↑↓	Arrows indicate shifts into especially high or low pitch
[soft talk]	Inaudible or unclear text
[ ]	Square brackets indicate researcher’s field notes/observations
( )	Words surrounded by parentheses indicate transcriber’s guess

Acknowledgements

The author extends her thanks and appreciation to all the participants (nursing students and faculty) who generously participated in this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

An Ethics Statement

Not applicable

ORCID iD

Abeer Mohammad

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