The data analysis clustered into four major categories: values, artistry, techniques and development (Table 1: overview of the emerging categories, themes and subthemes). These represent the totality of the debriefing practices described by the interviewees. These categories and their component themes and subthemes are described in the rest of this section, illustrated with representative quotes.
The interviewees explicitly and implicitly expressed core sets of ideas and beliefs that represented the fundamental principles that underpinned their debriefing practices. Three themes emerged philosophies, theories and impact. Interviewee’s values appeared relatively stable.
Most of the interviewees expressed a philosophy of debriefing; the debriefer is a facilitator, who must be dedicated, honest, genuinely curious and possess the abilities to facilitate a reflective debriefing.
“The idea of being an advocate and genuinely curious I think is fundamental to good debriefing.” Interviewee #13
Learner-centredness was a subtheme. This notion, of following the learners’ needs and objectives, was a common philosophy underpinning debriefing approaches.
Although few interviewees described explicit educational theories or theorists, there was an overwhelming constructivist influence in their practices. That is, the interviewees noted the importance of acknowledging the participants’ prior experiences and ideas, and their thoughts and feelings about the simulation activity . Constructivism was also manifested in their talk about scaffolding and experiential learning [36, 37]. Theorists that were cited included Kirkpatrick , Kolb  and Lave and Wenger . Some interviewees identified educationalists who had shaped their thinking about simulation and particularly their debriefing.
“I think whether you label someone an educational theorist or not, whether they've contributed something that contributes to education theory then that's important…. So lots and lots of people have contributed really important aspects that make up one big picture I think.” Interviewee #4
The interviewees described themselves as “doers” rather than “academics”; and there was an impression of regret as some interviewees expressed the desire to be more academically grounded.
There was a sense among interviewees that the debriefing creates an opportunity for all learners to adjust their perceptions of the world and reinforce, improve or change practice. In simulation, changed and improved practice is often displayed after the consecutive scenarios. Although there was perceived value in learners improving in simulation, the overall objective was to improve clinical practice.
“Pull out the salient bits that should be transferred to the real clinical environments because we really don't want people to be getting better at simulation, we want people to be getting better at clinical practice” Interviewee #4
Improvements that are promoted and reinforced through debriefing may potentially improve clinical practice.
Artistry refers to the “creative skill or ability”  noted in the interviewee’s descriptions of their practice. The themes within this category distinguish these interviewees as experts. The themes draw heavily from each other: “thinking on your feet” is required to blend models and manage learning objectives, and is also heavily informed by the personal characteristics of the debriefer.
Thinking on your feet
The first, and in some ways, the most significant theme of the artistry category, was the importance of being able to facilitate in a dynamic environment and “think on your feet” (Interviewee #12). This varied somewhat dependent on the learners’ level and the context. Across the three subthemes’ flexibility, balancing, and prioritising, there is an important idea of constant vigilance as debriefings may constantly change depending on learners’ interactions and reactions.
“Debriefings are very reactive. You have to be watching what’s happening as you’re going and modifying what you’re doing” Interviewee #17
Flexibility revolved around the notion that interviewees had a repertoire of debriefing methods on which to draw and made in-the-moment decisions to select the approach that best suited the current situation. This often led to a blended debriefing approach, which is expanded in the next theme.
Balancing and prioritising include managing the various different agendas inherent within a simulation.
A consistent theme was the interviewees’ blending of debriefing approaches , that is, the use of different models and techniques to approach debriefing.
“My personal approach is more of a blended approach I have to say. I know of all of the different styles of debriefing. I’ve found that no one style seems to fit me for all of the types of debrief that I do.” Interviewee #5
The interviewees’ blending of debriefing models and techniques was dynamic and dependent upon personal preferences, the learners’ perceived needs, and the scenario as experienced by the debriefer. This complex practice was therefore regarded more as artistry than as a technical process.
“Depending on what the simulation is and depending on what the participants are like when they enter the debriefing room, use all the different tools that are available to try and create your style for that particular debrief” Interviewee #16
The interviewees described having different strategies depending on the level of the learner and type of simulation or course. Strategizing was dynamic, as the way the scenario unfolds and the learners’ perception of the scenario may change the initial strategy. This counterbalanced thinking on your feet — it suggested that interviewees did not start the debrief de novo, but had a range of ways in which they could achieve their agenda. These strategies could include various techniques, as outlined below.
Artistry is reliant on the artist; this theme encapsulates the unique and personal approach that defines debriefing as a creative practice. Three subthemes emerged: frame, honesty, and stance. Frame relates to the interviewees’ background, preconceptions and experiences.
“… I think a background in emergency medicine is helpful from that perspective because I don't expect prescription for everything I see. I mean I've never had another background but I’m used to unexpected things and it doesn’t faze me.” Interviewee #12
Honesty enables a constructive discussion, but simultaneously, there was a sense that the presentation of honesty was dependent on the debriefer:
“I personally think that learners don’t value pussyfooting around tricky situations or tricky questions or answers. I think they just want to hear sometimes from the instructor what your view is” Interviewee #1
Debriefers also declared their stance, that is, their mental or emotional position adopted with respect to their judgements and opinions of the performances in the simulation. A common stance was taken on the importance of addressing unsafe practice, especially for clinicians.
“If there was some safety issue that came out of that session that they were unable to use a piece of equipment safely or they have some misconceptions that were dangerous and would lead to patient harm, they must be addressed before the end of the session because really if you don’t say anything then by omission they feel that that was an okay thing to do.” Interviewee #5
This category explores techniques used by the interviewees to promote a productive and safe learning environment.
Plan of action
This action-oriented theme is in some ways the practical application of the strategizing theme. It has three overlapping subthemes: structuring, methods, and sequencing. The interviewees consistently described a three-phase structure: reactions (e.g. learners venting or expressing emotions), discussion (e.g. sharing facts, summarising the scenario, facilitating reflection, seeking understanding, analysing actions) and summary (e.g. identifying take home messages, transfer to clinical practice).
“There’s a couple of different names for these but it’s the ones that have three phases, which is essentially gathering the information then analysing what actually happened and then basically taking it back to what did they learn from this process and what they can improve upon.” Interviewee #25
The structuring subtheme is about permitting learners to know what is happening and why, and to keep the debriefing on time.
“Make sure the participants know the structure of the debrief, how it will unfold, make sure they’re aware of their expectations and the rules” Interviewee #10
The methods subtheme captures the many approaches being used within the structure. The interviewees frequently mentioned Plus/Delta , Advocacy/Inquiry , and Pendleton’s model for feedback . The sequencing subtheme refers to the choices made regarding order of events or issues to be discussed during debriefing. Some of these were planned a priori, such as the use of the Plus/Delta  as an approach to facilitate prioritisation at the commencement of a debriefing.
Creating a safe learning environment
The interviewees described key features in creating a safe learning environment. There was no single approach for how to do this, but the interviewees emphasised establishing ground rules of respect and confidentiality, and setting the learners up for success with scenarios at the appropriate level of challenge. That is:
“being respectful of people by not purposely trapping them, so you’re actually setting up an area, a zone of safety in training by acknowledging that sometimes challenging things happen and why it’s been done that way.” Interviewee #3
The interviewees emphasised the importance of briefing before the scenario in which the expectations, rules and structure of the debriefing were outlined. How briefings were delivered varied considerably. Although briefings were mentioned by the interviewees to be essential for creating a safe learning environment, briefing practices are not the focus and have not been analysed independently. Other common techniques for creating a safe environment that promoted learning included assisting the participants to de-role after the simulation; setting the stage for the debriefing; acknowledging feelings of the participants; normalising incidents; and sharing responsibility.
Managing learning objectives
The role of learning objectives was discussed at length. The interviewees described how learning objectives were of major importance when designing a course or scenario in order to know what action to take, what to look for and when to terminate a scenario. Standardised courses like Anaesthetic Crisis Resource Management (ACRM), Advanced Life Support (ALS) and many student curricula require that prescribed learning objectives should be met. The interviewees had to balance these requirements with their core philosophy of learner-centredness:
“I think the learning objectives are important to determine the course of the scenario and to know when you met what you wanted to do with the scenario. However, I sometimes think that what you planned to happen in the scenarios didn’t always happen, it can be really quite dynamic.” Interviewee #3
Managing this tension requires the artistry of thinking on your feet:
“…you need to be flexible enough to actually deal with the learner's needs rather than the rigid learning objectives for that scenario” Interviewee #11
Likewise, the interviewees described prioritisation through confining the number of learning objectives, generally two to four, addressing different facets of practice depending on the learner group and the topics. There was a strong sense that too many objectives and learning was diminished.
“You can’t get through all the things that you pick up you’ve just got to do the important things and you can’t cover them all” Interviewee #14
Promoting learner reflection
Most of the interviewees believed that the debriefing is just the beginning of the reflective process intended to promote, enable and support the learners’ reflection and learning.
“I think the whole point really is that we’re getting them to review and reflect upon their practice” Interviewee #21
Some of the interviewees use the pause and discuss technique  to encourage and train reflection-in-action  with a notion of the potential transfer of this ability to clinical encounters. This technique was mostly used with learners who had little or no clinical experience. A technique used across all levels was outlining lessons learned with a view to enacting learning in clinical practice.
Co-debriefing was valued but not a common practice, as it was often constrained by logistics and cost. Benefits included offering of content expertise, especially when content experts lacked debriefing experience. Co-debriefing sometimes afforded added attention to individual learners and also for co-debriefers facilitated peer support, especially when training new debriefers.
“it’s also just useful to have two brains; you have two people watching the reactions and can redirect questions and can pick up on things you forget.” Interviewee #13
“Part of our debriefer mentoring program is that, particularly debriefers who are learning get mentored and get feedback after each debrief from their co-debriefer who is their mentor.” Interviewee #11
This category captures how the interviewees’ changed and developed their debriefing practice over time. A key part of development is reflecting on ways to improve debriefing and then enacting them.
The interviewees were generally aware of the transformations they had made to their debriefing practice over time. In particular, they noted an increased focus on the learners’ need:
“The main way it’s changed is recognising the fact that I couldn’t apply the same emphasis of debriefing phases to every group, that it needed to change all the time and identify which groups would need more of which aspect of debriefing and which part I’d focus on” Interviewee #25
Challenges described by the interviewees can be grouped into two categories: (1) personal and (2) organisational. The personal challenges were the most prominent. The interviewees found it to be a challenge, albeit one often with positive outcomes, to keep on top of new debriefing techniques and methods:
“Keeping on top of new techniques and ways of doing things and not becoming stayed in what you do. Just having the opportunity to discuss it with others and continue to learn from peers is important” Interviewee #2
The interviewees reported being challenged by lack of time to do simulation and to debrief; a few interviewees mentioned that debriefing participants with a different clinical background is sometimes challenging.
“On a interpersonal level I occasionally find that being a nurse debriefing doctors I have to prove my value so that they will listen.” Interviewee #19
Becoming comfortable with the uncomfortable
Through experience and experiment, most of the interviewees reported becoming more comfortable with the learners’ reactions to tricky situations and not knowing where the debriefing is going. The interviewees were aware of uncomfortable situations, and they use these as learning opportunities. In the process, they gained confidence and became relatively comfortable even in unexpected, challenging and uncomfortable situations.
“Accept that we will never become fully comfortable with the whole process no matter how many years’ experience you get” Interviewee #24
“Fundamentally my role is not to be their friend but that my role is to make them think about things and stimulate them to be reflective about their own practice” Interviewee #9
Care about their practice
Some of the interviewees expressed pride in being part of the simulation community and were humble about their own debriefing abilities. They expressed a continued interest to expand their knowledge and debriefing style. Curious to explore different approaches, the interviewees attended courses and workshops among other approaches:
“I'm of the belief if you ripe you rot very quickly so I think that you continuously need to improve and I think that the way to do that is by cross fertilising or going to other units and spending some time with them and adopting some of their methods and some of their ways on how to debrief” Interviewee #1
Learning from and with peers
The interviewees were deliberate in their use of peer feedback to improve and strengthen current debriefing practice, especially at simulation centres with a larger faculty. Those without peer faculty present for feedback have established peer relationships through the broader simulation community. This includes seeking feedback on recorded debriefings from geographically distant peers. The interviewees use observation of others’ debriefings as inspiration and positive or negative modelling. Peer feedback and observation of others performing debriefing were important pathways to gaining expertise.
“I learnt an enormous amount having the opportunity to practise my debriefing in front of my colleagues, even though I found it quite threatening initially” Interviewee #2
“I think the most constructive and important feedback that we have is from our colleagues” Interviewee #5
Many interviewees reported a rough start with debriefing, as isolated practitioners. They had experience of formal courses and self-study but for many, this came later in their development, and was secondary to the role of peer mentors.