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How to debrief teamwork interactions: using circular questions to explore and change team interaction patterns
© The Author(s) 2016
Received: 17 August 2016
Accepted: 26 October 2016
Published: 15 November 2016
We submit that interaction patterns within healthcare teams should be more comprehensively explored during debriefings in simulation-based training because of their importance for clinical performance. We describe how circular questions can be used for that purpose. Circular questions are based on social constructivism. They include a variety of systemic interviewing methods. The goals of circular questions are to explore the mutual dependency of team members’ behavior and recurrent behavior patterns, to generate information, to foster perspective taking, to “fluidize” problems, and to put actions into relational contexts. We describe the nature of circular questions, the benefits they offer, and ways of applying them during debriefings.
In the OR, do you feel that your colleagues share their points of view more frequently before or after the attending enters the OR?
Who can typically speak up the most to the attending when she seems stuck in unsuccessfully performing an unexpected difficult intubation?
These questions differ from the questions that we usually ask during debriefings, and they certainly differ from questions we use in our daily conversations. They are called circular questions [1–3]. Originally developed in systemic family therapy, they are useful for exploring and changing learners’ potentially gridlocked explanations of team interactions during debriefings [4–6].
In this manuscript, we describe the nature of circular questions, the benefits they offer, and ways of applying them during debriefings. Debriefings—the instructor-guided conversations among learners aiming to reflect on the relationships among events, actions, thought and feeling processes, and performance outcomes of the simulation—play a crucial role during simulation-based training [7–10]. Notably, we do not consider circular questions a new debriefing method on its own; instead, we regard them as an extension to any debriefing method aiming at making debriefings even more effective by helping learners gain new perspectives and understand teamwork patterns.
Debriefing team interactions
Teamwork and its components (e.g., leadership, communication) are typical content of learning objectives in simulation-based training [4, 5, 11–20]. This is important because effective teamwork has been linked to patient safety [21, 22]. Some teamwork components are attitudinal such as team orientation (i.e., preference for working with others) while others are behavioral and process-like such as leadership and mutual performance monitoring . Simulation-based training mostly addresses the latter. Team process is defined as “members’ interdependent acts that convert inputs to outcomes through cognitive, verbal, and behavioral activities directed towards organizing taskwork to achieve collective goals” (p. 357) . From our view, this team process, the interdependency of team members’ actions, and their importance for clinical performance are not yet fully explored during debriefings.
First, discussions during debriefings tend to be focused on team members’ individual behaviors and frames about their individual actions . This focus is important for uncovering the reasoning behind individual actions [9, 26]. Yet, it is potentially not sufficient for surfacing team dynamics because it does not yet allow for uncovering mutual dependency of behavior or self-reinforcing behavior patterns. Exploring these patterns would be beneficial: recent research has shown that it is particularly the pattern of behaviors among team members that discriminate higher from lower performing teams [27–32]. For example, during inductions of general anesthesia, higher-performing teams showed more talking aloud patterns than average-performing teams.  Also, teams engage in solution-oriented as well as complaining-oriented sequential patterns which are associated with positive and negative team mood, respectively [33, 34]. So far, these team interaction patterns have rarely been explicitly uncovered, explored, or altered in debriefings, resulting in missed opportunities for new information, perspectives, and change.
Second, by focusing on individual thought and feeling processes rather than on team interactions, instructors might overestimate the individual’s capacity and underestimate the influence of the context on the individual. Thus, we make, as Ross  described, the fundamental attribution error: we overestimate the individual learner’s disposition and personality and underestimate their environment and situational dynamics. With respect to teamwork, this means that instructors might overestimate the linear causality of teamwork behaviors and underestimate the circular causality of behaviors, that is the mutual dependency of behaviors; a person’s behavior at one time is considered both effect and cause of the interactional partner’s behavior . For example, while the assumption that the more internally willing individual team members were to speak up, the more effort they would put into actually speaking up would be based on linearity; the assumption that if team member A speaks up and team member B reacts with verbal appreciation, team member A might feel encouraged to speak up in future teamwork would be based on circularity. So far, circularity is rarely systematically explored during debriefings, missing an essential element of teamwork.
Why didn’t you speak up? – (Learner: “I don’t know.”)
not much is yet explored about the potential function of not speaking up for the system such as preserving hierarchy within the team, maintaining responsibilities or respecting sub-team territory [3, 18]. The resulting lack of new, different information tends to have a conservative effect on the learner, which may implicitly validate preexisting beliefs (e.g., that speaking up is too risky) . As a further result, instructors may stop exploring an issue in more detail because they feel that they have understood “enough”. This phenomenon has been called the confirmation bias, that is, seeking or interpreting information in a way that confirms existing beliefs, expectations, and hypotheses . Instructors are then at risk to develop solutions that do not fit the (not yet comprehensively discovered) problem .
In sum, we submit that circular interactional patterns within healthcare teams and their importance for clinical performance should be explored more comprehensively during debriefings. We propose that by applying systemic thinking and asking circular questions, instructors can actively use debriefings to walk the talk of teamwork.
The nature of circular questions
Circular questions are based on social constructivism and on circular assumptions about an issue [2, 39]. They were developed by the Milan Associates, a group of family therapists that fundamentally advanced the field of systemic family therapy . They described circular questions as an interviewing tool to explore a relationship between two people as it is seen by a third person by—in a somewhat complex way—inviting the third person to describe the relationship of two others in their presence. For example, a daughter is asked to describe how she sees the relationship between her sister and her mother or how everybody in the family reacts to a reported problematic behavior . Meanwhile, the term circular questions subsumes a variety of systemic oriented interviewing tools with the goal of exploring recurrent patterns and processes, generating information, fostering perspective taking, “fluidizing” problems, and putting actions into relational contexts [3, 40–42]. More specifically, by using circular questions interactions are explored with respect to differences in behavior rather than personality traits, ranking and classification, change in the relationship before and after an event, and differences in respect to hypothetical conditions.
Applying circular questions during debriefings
Considerations and requirements for using circular questions during debriefings
Considerations and requirement
Psychologically safe learning environment
Rudolph and colleagues have suggested a number of actions the instructor can take at the pre-briefing to establish a respectful and psychologically safe learning environment: for example clarifying mutual expectations, establishing a “fiction contract,” orienting to logistic details, and explicitly declaring and enacting a commitment to respecting learners and concern for their psychological safety .
Holding the learner in high regard
The “basic assumption,” as noted by Rudolph and colleagues, is an explicit statement to hold the learner in high regard: considering every participating learner intelligent, capable, doing their best, and wanting to improve .
Systemic assumptions about teamwork
Instructors benefit from (1) formulating hypotheses about team interaction patterns (hypothesizing), (2) investigating these hypotheses based on reactions of the team to information about aspects such as meaning, difference, change, etc. (circularity), and (3) triggering feedback and inquiring opinions rather than allying with specific team members (multipartiality) [1, 41].
As circular questions can be unfamiliar to the instructors and learners, previewing them to explicitly orientate the learners to this method may enhance understanding and transparency. For example, “I’d like to understand you more and would like to ask you an unfamiliar type of question: …” [50, 56].
Balancing advocacy and inquiry
If circular questions are used excessively, the instructor becomes impalpable to the learners and they might get frustrated from lack of direction and disengage from the debriefing . Learners will not only need to perceive the instructor as someone trustworthy but also as someone who is willing to share his or her thinking, point of view, and expertise [2, 9, 50].
How to use circular questions in debriefings
A trauma patient arrived in the emergency department. While handing the patient off, there seems to be confusion, many voices are heard, each team member seems to be engaged in action. There is no structured information exchanged or verbal planning. The paramedic repeats himself frequently, getting louder each time.
Approaching this episode systemically, the instructor might consider the paramedic as competent and experienced in performing patient handovers (respect), be curious about how team members mutually influenced each other and the paramedic’s behavior (e.g., in response to what behaviors by all team members did the paramedic start repeating himself; circularity) and the differences and similarities in each team members’ perception of the handover (social constructivism).
Explore how behavior varies according to contexts
“Fluidize” personality characteristics
Explore causal attributions and diverse views
Explore meaning of behavior within a context
Become a better observer of oneself
Encourage “other” awareness
Explore interpersonal perception
Explore interpersonal interaction
Highlight potential consequences
Explore catastrophic expectations
Explore future action
“When do your colleagues speak up most? … What is different in these situations?”
“What does she do when she does not seem to be interested in your opinion? … How do you explain that?”
“If he insists on doing the checklist, do you imagine he does this as a matter of principle or because he is convinced of its use in this situation?”
“In the OR, is there more speaking up before or after the attending joins the team?”
“How do you explain that she was shouting multiple instructions at the same time?”
“When you responded the way you did, how did you feel about your reaction?”
“If an intern had observed your interaction, what do think he might have learned from you?”
“What do you imagine he experiences when he gets into a situation like that?”
“What does he think that you think is going on when he starts yelling?”
To A: “What do you do when she starts doing the checklist without everybody being present? … And when you do this, what does she do?”
To B: “What do you do when he makes that comment? … And when you do this, what does he do?”
“If you continued not to talk about it, what do you expect would happen to the team?”
“What are you worried might happen if you said that you have never placed a central line before?”
“If she were saying ‘OK, I’ll take the lead’ when she is joining a resuscitation, what do you imagine the other team members would do?”
“If she were joining this critical situation as attending—do you imagine her first goal is to get an overview or distribute tasks among team members?”
When to use circular questions in debriefings
Hubert, when you hear Michael say that he has had these concerns during the scenario but did not voice them to Daniel, how do you explain this?
Hubert, you were able to observe the interaction between Michael and Daniel. I’m curious about your perspective, what do you think Michael might have needed from Daniel to speak up in that situation?
Furthermore, there a number of healthcare simulation debriefing situations in which circular questions may be particularly useful. We explain them in the following paragraphs.
When the instructor feels s/he would like to learn something new and explore a topic/frame deeper
From your perspective, what does someone do who has a sense of responsibility?
[to more team members] What else [does someone do who has a sense of responsibility]?
From your point of view, are these actions something that can be shared by all team members or should they remain with the team leader?
When the instructor feels that s/he is taking sides
If there was a good reason for not voicing your suggestions in this department, what would that reason be?
When the instructor feels that s/he is moving into an oppositional stance from the learners
What was different in instances in which you did speak up?
When the instructor wants to highlight different points of view among team members
In the OR, do you feel that your colleagues speak up more before or after the attending comes in?
Who else do you think might think this way?
Who do you think might be more skeptical?
When the instructor wants to explore circularity among team members
What do you do when she starts doing the checklist without everybody being present? […]
And when you do this, what does she do?”
How do you explain that he sometimes shouts multiple instructions at the same time in a trauma case?
In this manuscript, we have introduced circular questions as a way of debriefing team interactions. We have proposed that the interdependency of team members’ actions, and their importance for clinical performance should be more comprehensively explored during debriefings because (1) recent research has shown that rather than individual actions of single team members, it is the interaction pattern among team members that discriminate higher- from lower-performing teams [27–32], (2) by focusing on individual thought and feeling processes rather than on team interactions, instructors might overestimate the linear causality of teamwork behaviors and underestimate the circular causality of behaviors, and (3) by asking linear questions, instructors may tend to underestimate the meaning and messages of feelings, thoughts, and actions within a system, missing new information and team phenomena.
We have described the nature of circular questions and how they allow for exploring team behavior patterns, generating new information, and fostering perspective taking and observation skills in the debriefing. We have offered ways of applying circular questions and have recommended using them especially when the instructor (1) feels s/he would like to learn something new or explore something deeper, (2) feels that s/he is taking sides, (3) feels that s/he is moving into an oppositional stance to the learners, (4) wants to highlight different points of view among team members, and (5) wants to explore circularity among team members. We have highlighted that requirements such as creating a respectful and engaging learning environment and adopting a systemic mindset are ideally in place before using circular questions.
Notably, we do not consider circular questions a replacement for other debriefing methods. Within the framework of blended debriefing approaches [5, 6, 25, 48], we recommend circular question as one further instrument of the instructor’s debriefing toolbox to be used in combination with other instruments and integrated into an overall debriefing model, ideally the Debriefing with Good Judgment Approach . This embeddedness is essential to avoid disadvantages or pitfalls of circular questions such as appearing unfamiliar and strange, triggering surprising responses which catch the instructor off guard, or leaving the learner feeling interrogated. If circular questions are used excessively, the instructor becomes impalpable to the learners who might get frustrated from lack of direction and disengage from the debriefing . Learners will not only need to perceive the instructor as someone trustworthy but also as someone who is willing to share his or her thinking, point of view, and expertise [2, 9, 50]. Instructors are advised to balance questions and advocacies and maybe even preview circular questions as such.
So far, empirical research on circular questions is sparse and almost non-existent in the context of healthcare simulation debriefings . Research is needed to analyze debriefing interactions and their relation to debriefing outcomes and to investigate the effectiveness of circular questions. Also, more work is required to explore how circular questions can be integrated into simulation instructor faculty development programs as a method of debriefing team interactions by exploring the mutual dependency of team members’ behavior and recurrent behavior patterns, generating new information, and fostering perspective taking.
We hope this introduction of circular questions in simulation-based training will stimulate interesting debriefings, more research on debriefings, and help to walk the talk of teamwork during debriefings.
The research was supported by a grant from the Swiss National Science Foundation (Grant No. 100014_152822).
Availability of data and materials
MK drafted the manuscript with considerable input from BG, JS, and AM. All authors approve of the final manuscript and take responsibility for its content.
Michaela Kolbe is the director, Adrian Marty and Bastian Grande are the medical director and co-director, respectively, and Julia Seelandt is a research assistant at the Simulation Center of the University Hospital Zurich, providing simulation faculty development programs.
Consent for publication
Ethics approval and consent to participate
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