Effectively Co-debriefing an Interprofessional Team in a Simulation Context: A Systematised Review and Qualitative Study

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Incorporating IP co-debriefers mitigates power discrepancies and increases collaboration between debriefers and participants to optimise learning. Nevertheless, there are challenges that come with co-debriefing an IP team following a simulation, with limited recommendations for managing these challenges. This study aims to identify methods for how IP faculty can effectively debrief a post-licensure IP team following a Code Blue simulation. Methods This study conducted both a systematised literature review and a theoretical thematic analysis of post-simulation IP debriefing sessions. The search terms for PubMed and CINAHL were Debrief* AND (Interprofessional or multidisciplinary or interdisciplinary) AND simulation, with a date range of 2012–2022. Thirty articles were identified by title and abstract review, with 16 articles meeting the inclusion criteria. The thematic analysis was derived from post-simulation IP debriefing data collected from 12 simulation IP debriefs. These data included debrief-the-debriefer notes, participants’ post-debrief surveys, and a final debrief-the-debriefer session after all simulation sessions were complete. Results Five broad themes with nine subthemes were established by correlating the literature review findings alongside the post-simulation IP debriefing data and survey data: Effective Communication (use of specific questioning, discussion generation, empowering facilitators, and framework), Knowledge Gaps (specific education, empowering facilitators), Therapeutic Milieu (empowering participants, framing discussion, facilitator confidence/comfort), Effective Physical Structure, and Suggesting Tool Use. Conclusion Multiple strategies useful for IP co-debriefing were found, such as the use of an IP learner-centered approach with combined open-ended questions and specific questioning; the implementation of specific frameworks to guide the debrief; and the provision of IP debriefers educated in both simulation cases and debriefing. This study contributes to the research by acknowledging the uniqueness of IP co-debriefing compared with other debriefing models, and identifying effective strategies for IP co-debriefers to use in a post-licensure IP debrief. Further research should explore in-depth reviews of faculty debrief-the-debriefer sessions to inform a guiding framework for future debriefers. Debriefing Simulation Interprofessional Post-licensure learning Continuing education Background The use of simulations can enhance participants’ skills to improve their patient care in real-life scenarios. 1 – 3 Interprofessional education (IPE) in healthcare emphasises collaborative practices that involve two or more healthcare professionals working together to improve patient care quality. 1 Thus, practising simulated resuscitations in an IP setting prepares healthcare providers for realistic scenarios, incorporating collaboration and communication skills between professionals. 2 , 4 , 5 IPE can also lead to greater technical skills through role clarification between professionals and the reduced use of equipment. 4 , 6 , 7 Debriefing facilitates the growth of healthcare learners by reflecting on their performance and applying it to future practice. 5 , 8 , 9 There are different ways to debrief, however, no debriefing method is widely accepted as an optimal practice. 10 In an IP debrief, professional power discrepancies can negatively affect communication and collaboration between debriefers and team members. 11 , 12 It is imperative that debriefers use a collaborative approach to create an environment conducive to participant growth. This can be achieved by using IP co-debriefers, or two or more debriefers from different professions. 4 Using IP co-debriefers allows for deeper discussion with specialised knowledge, which targets the IP participants as a heterogeneous group. 1 , 13 However, the IP co-debriefer approach comes with challenges when attempting to consolidate participants’ knowledge as a partnership with diverse opinions and experiences. 1 , 13 Previous research has examined debriefing an IP team using a single debriefer; 14 – 17 or IP co-debriefers in a pre-licensure group. 8 , 18 – 22 There is limited literature exploring IP co-debriefing in a team of IP post-licensure professionals. While select variables have been explored including participant performance, 23 debriefing challenges and recommendations, 1 videoconference, 24 the use of a written tool, 25 , 26 and power dynamics, 12 there are no clear recommendations on how to successfully co-debrief a post-licensure IP team following a simulation. This study therefore aimed to do the following: Identify strategies for IP co-debriefers to use that are beneficial to debriefing a post-licensure IP team following a simulation. Identify solutions to common challenges presented to IP co-debriefers while debriefing a post-licensure IP team following a simulation. Methods This study had two approaches: a systematised literature review (Additional File 3) and a collection of qualitative data from post-simulation IP debriefing sessions. The results from the literature review were used to inform and compare the data gathered from the debriefing sessions. A summary of the systematised review can be found in Appendix A . Research Paradigm This qualitative study focuses on interpreting human experiences in words; thus, a combination of constructivist and grounded theory research paradigms was used. 27 Constructivism is a philosophical orientation that suggests that reality is dependent on a person’s perceptions and that reality and fact are determined by experiences. 27 This approach is applicable to the research question posed, as the goal is to determine strategies to effectively debrief an IP team via written and verbal feedback and experiences. Grounded theory generates theory from data; the data relevant to the research purpose emerges through analysis. 27 In this study, the identified themes surfaced from the data collected. Study Design The study was conducted at a tertiary care hospital located in Northern Ontario and approved in November 2021 by the Health Sciences North (HSN) Research Ethics Board (REB) (project number 21–040). Four simulation cases were created for this study. Each case was repeated three times with a control case in between, running from December 2021 to December 2023. A total of 12 simulations were hosted in this period, since some cases were not run due to participant sickness and unavailability. Each case included variable medical complexities that resulted in a cardiac arrest and the need for resuscitation. The participants were pre-briefed on the simulation and research components of the study. Following the pre-brief, participants engaged in a 20-minute simulation, where the debriefers used an original debriefing reference checklist (Additional File 1) to keep track of the case events, participant roles, and organise the topics needed to debrief. After the simulation, the debrief was hosted for 40 minutes by two trained IP debriefers, who were physicians, registered respiratory therapists (RRTs), or registered nurses (RNs). At minimum, a physician and non-physician hosted the debrief. A co-debriefing checklist formulated by Cheng et al. 28 was used to ensure a thorough pre-to-post debriefing process. During the debrief the PEARLS framework, developed by Eppich and Cheng 29 was used as a tool to guide the debrief. After the simulation participant debrief, the participants completed a Likert-scale survey with open-ended questions on the simulation and the debrief (Additional File 2). Another 20-minute debrief-the-debriefer session occurred while the participants completed the surveys. During this time, the debriefers discussed strategies that worked, challenges that arose, and future changes that could be made, while a researcher scribed the discussion. The data collected from the debrief-the-debriefer sessions, as well as the data from the participant surveys were used for thematic analysis. Sampling The simulation participants were included on a voluntary basis and recruited via convenience and snowball sampling by morning announcements or sign-up forms in each respective department. The participants for each simulation included two critical care RNs (Emergency Department and Intensive Care Unit), one RRT, and two physicians, usually Emergency Medicine, Internal Medicine, or Anaesthesia residents, although occasionally supplemented with Emergency or Intensivist physicians. Purposeful sampling was used for the debriefing participants as they were known as experienced debriefers through previous simulations and were contacted for voluntary participation in the study. Each simulation used different debriefers on the basis of availability. As this phenomenological study examines experience, feedback, and opinions from the expert debriefers, purposive sampling is appropriate. 27 Data collection The data collected were a mix of four different sets. All data were collected in Microsoft Word documents and saved to a BitLocker-protected hard drive, which was password-protected and locked in the simulation laboratory. The first data set consisted of notes from the debrief-the-debriefer sessions, the second set was a summary of each debrief-the-debriefer session, typed by the same researcher who scribed the debrief-the-debriefer data, and the third data set included qualitative data from the participant surveys. The fourth data set occurred 20 months after the project started as a method of ensuring data saturation. This data set consisted of a two-hour-long, in-person, recorded and transcribed debrief-the-debriefer session, where the study debriefers were asked a set of questions on their experiences. Thematic Analysis Qualitative data are best explored by categorising and recognising patterns to describe the phenomenon. 30 , 31 Thus, a theoretical thematic analysis was conducted on the basis of a modified Braun and Clarke’s 6-Step Framework. 30 In the first phase, the goal is to become familiar with the data. Two authors read through the data sets twice prior to coding. All data not related to debriefing were removed. The second phase included generating preliminary codes based on related concepts. The third phase involved searching for themes, which was performed simultaneously with the second phase. In the fourth “reviewing themes” phase, both authors worked together and shared their initial themes, which were broken down into subthemes, grouped, and eliminated. This was transcribed to another document with descriptions for each theme, concluding the fifth phase, ‘defining and naming themes’. If subthemes were included, they were defined and incorporated into the broad themes. Finally, the ‘producing the report’ phase was completed and is described in the results section below. A similar approach was used to conduct the thematic analysis from the final debrief-the-debriefer session; however, for this data set, Atlas.ti was used for manual coding and theming. Results Five broad themes with nine subthemes were established. The themes and their subheadings are as follows: Effective Communication (use of specific questioning, discussion generation, empowering facilitators, and framework), Knowledge Gaps (specific education, empowering facilitators), Therapeutic Milieu (empowering participants, framing discussion, facilitator confidence/comfort), Effective Physical Structure, and Suggesting Tool Use. The themes can be found in Table 1 , at the bottom of the manuscript. Table 1 Themes from the post-simulation IP debriefing data and survey data. Broad theme Subtheme Number of subtheme occurrences Description Example Effective communication Use of specific questioning 10 Using specific wording when asking a question directly “What strategies could you have utilised to get help from your team?” Discussion generation 12 Phrases or strategies that allow participants to reflect verbally “How did that feel?” Empowering facilitators 10 Giving the debriefers strategies and support to confidently lead a debrief “Novice staff need more support and orientation” “Using the phrase ‘I am curious why…?’ to navigate intimidating participants Framework 2 Using a specific framework to follow to guide the debrief PEARLS Knowledge gaps Specific Education 5 The use of specific tools, policies, or guidelines to help support specific debriefing topics “Could have used the ACLS algorithm cognitive aid more directly in the debrief” Educating facilitators 3 Ensuring facilitators are educated and credible on the subjects they are teaching “Review ACLS – focused inquiry in reflection to ACLS algorithm” Therapeutic Milieu Empowering participants 7 To be able to contribute for a meaningful and safe debrief “Leave on positive note and ask learners for their key take away points” “Put yourself in vulnerable position to support participants and normalise their feelings” Framing discussion 4 How phrases are used versus what phrases are used “I agree…. here’s what went well” Use “how did that feel?”; avoid “how do you feel that went?” or “how did you think you did?” Facilitator confidence/ comfort 8 Strategies that were used to increase the debriefer’s belief that they are capable of successfully debriefing “Providing the debriefers an opportunity to practise their thoughtful questioning during the safe and supportive environment of this ‘debrief the debriefer session’” “Change your chair position, shift your papers, stand up etc…. change your physical position to divert the conversation in a new direction” “Playing on facilitator strengths” Effective Physical Structure 13 Ways that the physical environment helped create a space conducive to debriefing Positioning in a triangle Having multiple IP debriefers Having more time for debrief Debrief-the-debriefer session Pre-brief discussion framing Specific Tool Use 3 The use of specific tools to complement the debrief Use of videos during debrief From the final debrief-the-debriefer session, three broad themes with 22 subthemes were officially established. The themes and their subheadings are as follows: Technique (circling back, discussion generation, framing discussion, nonverbal cues, learned-centred, positive reinforcement, safety, framework), Facilitator (coaching, debriefer feedback, mentorship, training, empowering facilitators, expertise, internal facilitator feedback, reflection), and Participant (curious intentions, positivity, empowering participants, interdisciplinary, personal experience, teamwork). These themes are not tabled since they are adjuncts to the discussion. Discussion The themes and subthemes are discussed relative to the literature from the data collected from the debriefing sessions. Effective communication The overarching theme, ‘Effective Communication’, is used to break down ways in which the debriefers noticed phrases used to allow participants to reflect to self-guide the debrief. Use of specific questioning In the case where the team leader may require assistance from their team members, the question “What strategies could you have utilised to get help from your team?” was asked. This direct, yet open-ended question allows participants to reflect on a situation with a specific goal in mind. This specific questioning method avoids neutral statements by debriefers that can confuse participants and fail to address the learning objectives. 26 Another specific question that was frequently used is “If you had to turn back the clock, what or how would you have done differently?”. This allowed the participants to reflect on the key learning points that occurred during the simulation. However, direct questioning may not always benefit participants. For example, if a participant incorrectly uses the ACLS algorithm, directly asking them the steps of the algorithm may compromise the learner’s psychological safety. Specific questioning with more sensitive subjects could be beneficial or harmful depending on the context and perception. 1 However, in the right context, specific questioning generates discussion, avoids confusion, and can be useful for the participant’s learning outcomes. Discussion generation “Discussion generation” encompasses any phrase that gives participants the opportunity to speak in a psychologically safe space. For example, using the beginning phrase “how did that feel?” allows participants to delve into their initial thoughts without immediately explaining the rationale. This phrase is used in the ‘Reactions Phase’ of the PEARLs framework where all comments are held until each participant has a chance to express how they feel. 29 The use of open-ended questions allows participants to reflect on their actions and answer questions on their own perceptions. 32 Finally, an important discussion-generating point is to be more of a moderator than a contributor. A tip for learner-centred debriefing is to direct any questions asked back to the group for discussion. 32 This creates less of a lecture-style debrief and more of a collaborative approach. The discussion is particularly generative in debriefs with post-licensure IP participants who have extensive knowledge that they can share between each other. 10 Furthermore, a debriefer who directly informs the participants of their performance removes the opportunity for them to direct the learning process. 33 There is an inverse relationship with facilitator contributions and learner engagement, and learner engagement increases by asking questions themselves. 10 Eventually, if the participants are unable to come to a conclusion about the question, the facilitator can contribute. Empowering facilitators There are many strategies to help debriefers feel less intimidated by participants, which was a challenge in this study. First, debriefers should avoid debating, which may further lead to a power imbalance. 34 To manage the intimidation, ask the participant “I am curious why…?” in a genuine tone to encourage understanding of the participant’s perspective. This may be helpful for non-physician debriefers, since the stereotype that physicians are academically stronger than other faculty members can be a barrier to IP contribution. 10 It was evident in this study that newer debriefers seek more direction when debriefing. Some proposed strategies for beginner debriefers are to understand the importance of debriefing, apply related debriefing tools, and create a psychologically safe space for participants to increase their contribution. 36 Once these skills are solidified, the debriefer can apply their knowledge to optimise co-facilitation. Overall, the theme “empowering facilitators” coincides with two other themes, “facilitator education” and “facilitator confidence/comfort” which differ slightly depending on the context. Framework A written framework was used to guide the debriefs in this study (PEARLS). 29 Using PEARLS in the debrief-the-debriefer sessions ensured that minimal learning points were missed. Using a framework is useful for novice debriefers, who may require more support. 29 Additionally, using a framework provides educational support for other IP members who are debriefing physicians, who potentially have more training than their allied health counterparts do. As the debriefer gains experience, it is suggested to follow the framework but modify it based on the specific needs of the participants and context. 29 Furthermore, the literature suggests that using a framework while debriefing significantly improves learning outcomes for participants. 17 The use of a written tool while debriefing shifts the focus from the facilitator to learner-self assessment. 26 The goal is to allow participants to guide the discussion in a reflective manner. Debrief-the-debriefer session : During the debrief-the-debriefer session, the subthemes of “discussion generation” and “framework” were both highlighted. Debriefers reflected on the subtheme “Framework”, acknowledging the importance of using an evidence-based outline during the debrief session and guiding debriefers to remain systematic in their debrief. One debriefer commented on this: “I think that brings on the importance of when you do this, [have] a game plan. You know, we showed up to these scenarios with the objectives for the learners, but [also with] objectives for the debriefers” Knowledge Gaps The broad theme ‘knowledge gaps’ is used to address strategies that are effective in closing participants’ knowledge gaps in specific domains, such as ACLS guidelines and specific equipment challenges. Specific education The subtheme “specific education” refers to the use of policies or guidelines to help support specific topics during the debrief. For example, one tool that is commonly used is the American Heart Association (AHA) ACLS algorithm. 25 During the debrief-the-debriefer sessions, the ACLS algorithm could have been used as a cognitive aid for the team during the debrief to solidify participants’ visual needs. Additionally, there were challenges associated with specific equipment, particularly the portable defibrillators. Rather than solely discussing these challenges, it was suggested that the equipment be brought into the debrief to be practised utilising it. Critical performance issues that arise must be a priority of discussion. 33 Mistakes made when equipment is used must be addressed to prevent future errors. Furthermore, if mistakes are made in the ACLS algorithm or other critical care interventions, it is key to delve into these mistakes in a sensitive, inquisitive manner. 1 Approaching sensitive conversations with a neutral approach can be confusing for the participants and should be addressed cautiously but directly. 26 Facilitators should be educated on the content in which the simulation is about, which will be elaborated on in the next section. Educating facilitators . A point that emerged from the data was that debriefers should have a strong understanding of the material on which they are debriefing. If the simulation requires following the ACLS algorithm, the debriefers should have a deep understanding of this, or else use the cognitive aid during the debrief. 33 However, participants value debriefing credibility just as they value clinical credibility. 1 IP co-debriefing is an effective way to mediate this. Experienced healthcare professionals can be trained in debriefing courses and gain experience in smaller debriefs prior to co-debriefing an IP session. In this study, novice debriefers were offered a two-and-a-half hour debriefing course highlighting co-debriefing and IPE strategies. Nonetheless, this study’s findings did not highlight any issues with the credibility of the debriefers but rather the energy the debriefers emitted. One participant commented that “more enthusiasm from [the] facilitator would create a better space for discussion”. Correspondingly, debriefers should demonstrate motivation and enthusiasm to engage the participants in the discussion. 33 Debrief-the-debriefer session In the Facilitator theme, several subthemes relate to the simulation data collected above. For example, training, expertise, mentorship, reflection and coaching were all subthemes that highlighted qualities that benefit the debriefer. Training and coaching refer to specific training as a debriefer and receiving guidance from experienced debriefers. “There was a strength [in] being able to debrief the debriefer in a formal manner… [it was] pretty critical to getting people [to] feel confident. And… practising the road map… following the framework for [de]briefing and being able to try new things” Therapeutic Milieu The theme ‘therapeutic milieu’ is used to discuss strategies that create a safe space for participants. Empowering participants This subtheme highlights the need for participants to feel safe, confident and able to contribute to meaningful discussion during the debrief. An interesting point from the data was that team members who were newer in their profession were not comfortable giving feedback to the group because they were feeling inexperienced. Holmes and Mellanby 1 noted that anxiety was heightened in junior staff when they were asked to speak in front of colleagues, especially when there were more senior staff. A recommended strategy was to use specific questioning with caution directed at junior learners. 1 If they are hesitant to answer, changing the focus to another participant is wise to maintain a psychologically safe learning space. Specifically, disclosing the debriefer’s own uncertainties and being vulnerable to participants was an effective strategy in this study. A specific phrase that was used to normalise a participant’s feelings was “uncertainty is a really uncomfortable feeling for me”. Normalising a participant’s feelings when an emotional situation arises during the debrief creates a psychologically safe learning environment for participants and is more likely to create the desired change. 34 Moreover, providing validation does not imply that the debriefer agrees with the participant’s course of action, however, it does confirm that the debriefer is listening and that the participant’s perspective is important. 34 Framing discussion Framing the discussion refers to how something is said, not what is being said. For example, in this study, careful caution was used during the initial “reaction” phase to say, “How did that feel?” rather than “How do you think you did?”. When the latter was used, the participants often proceeded to discuss their perceived mistakes. A safe learning space, which is enhanced by positive reinforcement, is necessary for development. 33 A method used in this study to reinforce a positive learning environment was to encourage positive comments in each participant's performance. For example, if a participant discusses their contributions to the simulation, the debriefer can respond with “I agree… Here's what went well”. However, mistakes must also be discussed but should be viewed as learning opportunities rather than negative aspects of the simulation. 33 Practical mistakes are commonly made during simulation, so it is important to pre-brief prior to the simulation and ensure that each participant is aware that the simulation and debrief are safe learning spaces and that every participant is believed to be there for growth and development. 32 Caution should be exercised when framing the discussion, as sometimes the way a debriefer says a phrase may not frame the discussion how they intended. For example, in one of this study’s cases, the question “Do you think it was your experience that led you to think you did not need to designate roles?” was asked to an IP participant. The intent was to allow the participant to reflect on the ACLS algorithm and highlight the use of their IP team members; however, the debriefer’s question was answered by themself. A more suitable frame would be “I am curious about your thought process when you are deciding which direction to take with the patient”. This allows the participants to run through their decision-making process and ask for clarification if needed. Overall, discussions should be framed positively to enhance psychological safety and clearly to avoid confusing the participants. Facilitator confidence/comfort Facilitator confidence and comfort refer to strategies that are used to increase the debriefer’s belief that they are capable of successfully debriefing and benefitting the participant’s learning needs. For example, debriefers were given the opportunity to participate in two-and-a-half hour debriefer training to promote confidence in debriefing techniques. Then, in the debrief-the-debriefer session, the facilitators practised debriefing on each other to receive feedback on how the participant may have perceived the question. The literature highlights that co-debriefing can be used to enhance faculty development through peer feedback. 13 Additionally, in the debrief-the-debriefer session, co-debriefers can discuss the challenges of the simulation to benefit their own learning needs for the next debrief. Another display of facilitator confidence is the use of body language, which displays focus from the debriefer on to the participant. 32 In this study, shifting papers or changing positions were the strategies used to divert the participants’ attention. A last example of increasing a debriefer's confidence is to play on the facilitator strengths. For example, if one of the debriefers is a RRT, discussing the airway during the debrief will be a comfortable topic in which the debriefer is well versed. This is an advantage of IP co-debriefing, as having different types of expertise combined provides a larger scope of specialised knowledge to deliver to participants. 13 Debrief-the-debriefer session Finally, in the debrief-the-debriefer data, the subtheme “empowering participants” was the dominant theme. The debriefers commented on the importance of allowing the participants to lead the discussion. “ … [you have to] try to enable them to come up with their own conclusion and thoughts”. “Mind you, I don’t actually think [the] debriefer’s role is to give any feedback. I think it’s to elicit feedback from the team”. Effective physical structure The theme ‘Effective physical structure’ is used to describe ways in which the physical environment helps create space and time conducive to debriefing. In this study, the physical environment was optimised by debriefers arranged in a triangular shape with three debriefers or across a table with two debriefers. This allowed the debriefer to view each other’s nonverbal cues. 13 Next, having multiple IP debriefers was necessary for the purpose of this study; however, it is very beneficial to have multiple debriefers as this provides more than one area of specialty to benefit the participants. 13 The need for more time during the debrief was noted by two participants. The debriefs in this study were 40 minutes, which is twice as long as the simulation. There are no clear guidelines on how long a debrief should last; however, a common length of time for debriefing is two to three times the length of the simulation, with some suggestions saying five-times the length of the simulation. 32 Additionally, the debriefers in this study mentioned that having a debrief-the-debriefer session was beneficial for overcoming challenges and improvements for future debriefs. Finally, framing the discussion with a pre-brief mention of confidentiality, encouraging participation, and ensuring the setup for psychological safety of the participants allows the debrief to begin smoothly with learning objectives identified and ready to be discussed. Suggesting tool use The “Suggesting tool use” theme is used to describe specific tools that debriefers agreed may be beneficial for future debriefs. In this study, the use of video for the simulation was mentioned three times. There is literature that supports the use of video during a debrief; however, there is no consensus on whether it affects participants’ learning outcomes. 33 Some benefits of video include: increasing selected behaviours in the future, enhancing reflective reasoning, and allowing for on-the-spot reflection. 33 Overall, the use of video during a post-IP-simulation debrief requires further research to examine its impact. Limitations One limitation of this study is that the qualitative data gathered to identify effective methods of debriefing were collected by the debriefers. Collecting data from the participants would provide valuable insight into what changes should be made in the debriefing process to suit the needs of the participants. The literature review was limited to PubMed and CINAHL. For a more scoping review, Google Scholar and other databases could have been used. In future research, PRISMA guidelines could be followed for a systematic review. Some of the simulations were cancelled because of sickness and low participation. If all simulations were performed as planned, more data could have been collected from the debriefing-the-debriefer meetings. Future research could examine the factors affecting simulation participation and this could be implemented in future simulations for optimal participant retention. Conclusion Overall, this paper intended to highlight effective methods and strategies that the IP faculty could use to effectively debrief an IP team after a Code Blue simulation. Multiple strategies were identified through a review of the literature and data collected from the simulations hosted for this study. Some suggestions agreed upon by the literature and this study’s data include and are not limited to using an IP learner-centred approach with combined open-ended questions and specific questioning, using specific frameworks to guide the debriefing (such as PEARLS, created by Eppich & Cheng) 29 , and using IP co-debriefers who are educated in the topic of simulation as well as trained in debriefing. Further research should examine IP co-debriefing strategies from the perspective of the participants, rather than the debriefers, to add to the body of knowledge from the debriefing perspective. Incorporating both aspects of debriefing would complete a global perspective and suit the needs of all members involved in the debriefing. Declarations Author Contribution E.M wrote the main manuscript, prepared Table 1, Appendix A, and Additional File 4, and performed the thematic analysis of the qualitative study and literature review with M.S. A.B. organized and managed the project from start to finish, with assistance from H.S. H.S. and A.B. collected the data for the qualitative study and contributed largely to edits. All authors reviewed the manuscript and approved it before submission. Acknowledgement Dr. Nicholas FortinoKyle Mispel-BeyerChristine BickRenee FillierKayla Noble Data Availability The datasets generated and analysed during the current study are not publicly available due to confidentiality reasons that would compromise individual privacy, but are available from the corresponding author on reasonable request. References Holmes C, Mellanby E. Debriefing strategies for interprofessional simulation—a qualitative study. Advances in Simulation. 2022;7(1):18. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9206121/ Klipfel JM, Carolan BJ, Brytowski N, Mitchell CA, Gettman MT, Jacobson TM. Patient safety improvement through in situ simulation interdisciplinary team training. 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Creating psychological safety in interprofessional simulation for health professional learners: a scoping review of the barriers and enablers. Journal of Interprofessional Care. 2023;37(2):187–202. Available from: https://www.tandfonline.com/doi/pdf/10.1080 /13561820.2022.2052269?casa_token=Hc5Vyv5rOf0AAAAA:senbFUgU0qB0sEj8wfYr9AjmCPwO3p6P5eEaLIKeVhn504iYbnAiGs44GkOKfMYx6OSH7vjMqkCE Robertson K, Ju M, O’Brien BC, van Schaik SM, Bochatay N. Exploring the role of power during debriefing of interprofessional simulations. Journal of Interprofessional Care. 2022 Mar 31:1–9. Cheng A, Palaganas J, Eppich W, Rudolph J, Robinson T, Grant V. Co-debriefing for simulation-based education: a primer for facilitators. Simulation in Healthcare. 2015;10(2):69–75. Boet S, Bould MD, Sharma B, Revees S, Naik VN, Triby E, Grantcharov T. Within-team debriefing versus instructor-led debriefing for simulation-based education: a randomized controlled trial. Boet S, Pigford AA, Fitzsimmons A, Reeves S, Triby E, Bould MD. Interprofessional team debriefings with or without an instructor after a simulated crisis scenario: an exploratory case study. Journal of Interprofessional Care. 2016;30(6):717–25. Cheng A, Hunt EA, Donoghue A, Nelson-McMillan K, Nishisaki A, LeFlore J, Eppich W, Moyer M, Brett-Fleegler M, Kleinman M, Anderson J. Examining pediatric resuscitation education using simulation and scripted debriefing: a multicenter randomized trial. JAMA pediatrics. 2013;167(6):528–36. Endacott R, Gale T, O’Connor A, Dix S. Frameworks and quality measures used for debriefing in team-based simulation: a systematic review. BMJ Simulation & Technology Enhanced Learning. 2019;5(2):61. Andersen P, Coverdale S, Kelly M, Forster S. Interprofessional simulation: developing teamwork using a two-tiered debriefing approach. Clinical Simulation in Nursing. 2018;20:15–23. Available from:. https://www.sciencedirect.com/science/article/pii/S1876139917303018?casa_token=RI0H3 U_-vgoAAAAA:dxQ1JMijKGEWj6jvK_sHRPmyhlZlAJPMSaXvF60SgqaoCnKZJlgdxGRfMKf1lbLlPWDzcGs71A Glatts L, Clark N, Clarke S, Fukuyama K. Student perspectives of interprofessional group debriefing: Use of the National League for Nursing Guide for Teaching Thinking. Nursing Education Perspectives. 2021;42(1):36–8. Meny LM, de Voest MC, Salvati LA. Assessment of student pharmacist learning within an interprofessional simulation: A comparison of small group vs. large group debriefing. Currents in Pharmacy Teaching and Learning. 2019;11(5):533-7. Available from: https://www.sciencedirect.com/science/article/pii/S1877129718303447?casa_token=r1TavJ-jpIQAAAAA: 2kPO9RKh0e22qIBRIk3YJCdF2eOSt2f8yWg6_J330GP6ddt6gmQRvDcpMqXmiG30NdypeBWnYFI Nyström S, Dahlberg J, Edelbring S, Hult H, Abrandt Dahlgren M. Debriefing practices in interprofessional simulation with students: a sociomaterial perspective. BMC medical education. 2016;16:1–8. Paige JT, Garbee DD, Yu Q, Zahmjahn J, de Carvalho RB, Zhu L, Rusnak V, Kiselov VJ. Brick in the wall? Linking quality of debriefing to participant learning in team training of interprofessional students. BMJ Simulation & Technology Enhanced Learning. 2021;7(5):360. Houzé-Cerfon CH, Boet S, Saint-Jean M, Cros J, Vardon-Bounes F, Marhar F, Couarraze S, Der Sahakian G, Mattatia L, Nicolle L, Balen F. Effect of combined individual-collective debriefing of participants in interprofessional simulation courses on crisis resource management: a randomized controlled multicenter trial. Emergencias.[Internet]. 2020;32(2):111–7. Dalinghaus K, Regehr G, Nimmon L. Intersections of power: videoconferenced debriefing of a rural interprofessional simulation team by an urban interprofessional debriefing team. Perspectives on Medical Education. 2021;10(5):286 – 92. Kolbe M, Weiss M, Grote G, Knauth A, Dambach M, Spahn DR, Grande B. TeamGAINS: a tool for structured debriefings for simulation-based team trainings. BMJ quality & safety. 2013;22(7):541–53. Thompson R, Sullivan S, Campbell K, Osman I, Statz B, Jung HS. Does a written tool to guide structured debriefing improve discourse? Implications for interprofessional team simulation. Journal of Surgical Education. 2018;75(6):e240-5. Lobiondo-Wood G, Haber J, Cameron C, Singh MD. Nursing research in Canada: methods, critical appraisal, and utilization. 3rd ed. Toronto: Elsevier; 2014. Cheng A, Grant V, Huffman J, Burgess G, Szyld D, Robinson T, Eppich W. Coaching the debriefer: peer coaching to improve debriefing quality in simulation programs. Simulation in Healthcare. 2017;12(5):319–25. Eppich W, Cheng A. Promoting Excellence and Reflective Learning in Simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simulation in Healthcare. 2015;10(2):106–15. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology. 2006;3(2):77–101. Maguire M, Delahunt B. Doing a thematic analysis: A practical, step-by-step guide for learning and teaching scholars. All Ireland journal of higher education. 2017;9(3). Available from: http://ojs.aishe.org/index.php/aishe-j/article/view/335 Ross S. Twelve tips for effective simulation debriefing: A research-based approach. Medical Teacher. 2021;43(6):642–5. Lyons R, Lazzara EH, Benishek LE, Zajac S, Gregory M, Sonesh SC, Salas E. Enhancing the effectiveness of team debriefings in medical simulation: more best practices. The Joint Commission Journal on Quality and Patient Safety. 2015;41(3):115 – 25. Available from: https://www.sciencedirect.com/science/article/pii/S1553725015410165 Grant VJ, Robinson T, Catena H, Eppich W, Cheng A. Difficult debriefing situations: A toolbox for simulation educators. Medical teacher. 2018;40(7):703–12. Neumar RW, Shuster M, Callaway CW, et al. 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18). Available from: https://doi.org/10.1161/CIR.0000000000000252 Cheng A, Eppich W, Kolbe M, Meguerdichian M, Bajaj K, Grant V. A conceptual framework for the development of debriefing skills: a journey of discovery, growth, and maturity. Simulation in Healthcare. 2020;15(1):55–60. Andersen P, Coverdale S, Kelly M, Forster S. Interprofessional simulation: developing teamwork using a two-tiered debriefing approach. Clinical Simulation in Nursing. 2018;20:15–23. Paige JT, Zamjahn JB, Carvalho RB, Yang S, Yu Q, Garbee DD, Kiselov VJ, Rusnak V, Bonanno L, Callan C. Quality with quantity? Evaluating interprofessional faculty prebriefs and debriefs for simulation training using video. Surgery. 2019;165(6):1069–74. Nyström S, Dahlberg J, Edelbring S, Hult H, Abrandt Dahlgren M. Debriefing practices in interprofessional simulation with students: a sociomaterial perspective. BMC medical education. 2016;16:1–8. Appendix A Systematised review The aim of the literature review was to explore the literature on debriefing after an IP simulation, specifically to identify strategies used to effectively co-debrief an IP team and challenges that may arise during the debriefing process. The authors implemented a systematised review that enacted search strategies, multiple reviewers, columns, and specific inclusion and exclusion criteria to gather the latest information on IP debriefing. The Pubmed and CINAHL databases were used for the literature review. The search terms for each database were Debrief* AND (Interprofessional or multidisciplinary or interdisciplinary) AND simulation, which were informed by the Holmes and Mellanby review. 1 The inclusion criteria for the papers were any full-text, English language article that included IP healthcare-based simulation and debriefing, whereas the exclusion criteria were non-full text articles, articles not in the English language, non-IP participants and single debriefers. Subset analyses were performed to differentiate between pre-licensure participants and post-licensure professionals to identify differing themes. A total of 58,406 items were identified from the database via the search terms. After the title review, 215 items remained. After the abstracts were reviewed, 30 articles were identified for full-text review. Three articles were excluded from the full-text review because they did not include IP participants or co-debriefers. Eight articles were initially included for secondary review but were ultimately excluded because they did not meet the needs for either IP simulation or co-debriefing. After thoughtful review of the articles in the context of the inclusion and exclusion criteria, 15 articles were included since they had most of the research components, and the decision was made to include the pre-licensure and post-licensure subset analyses. The entire literature review can be found as Additional File 3 labelled “Literature Review”. Additional Declarations No competing interests reported. Supplementary Files AdditionalFile1CoDebriefingChecklist.pdf AdditionalFile2InterprofessionalCodeBlueTrainingParticipantEvalFormAug20212.docx AdditionalFile3LiteraturereviewEffectivelyCodebriefinganInterprofessionalTeaminaSimulationContextASystematisedReviewandQualitativeStudy.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5391952","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":374645357,"identity":"c10115de-6c44-4483-907f-5348dde5f547","order_by":0,"name":"Emma-Liisa Makinen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvUlEQVRIiWNgGAWjYHACZoYEIMlPuhbJBpK0gIDBAWLV84sdfmzwcIdNnvHt5sOfbjDYyRPUIjk7zTgh8UxasdmdY2nSOQzJhgQdaHA7wfhAYtvhxG03csyYcxgOMBLUYn87/TNQy//EzTNyjD8DtdgTtkU6B+iwtgOJGyRygGyGA4kEtUjczik2SGxLTpxxIw3oF4PkZIJa+Genb5b82WaX2D8j+fDnnAo7W4Ja0N1JovpRMApGwSgYBdgBAN4NPUFQSL/OAAAAAElFTkSuQmCC","orcid":"","institution":"NOSM University","correspondingAuthor":true,"prefix":"","firstName":"Emma-Liisa","middleName":"","lastName":"Makinen","suffix":""},{"id":374645358,"identity":"aeb9f8b1-45b0-47ee-822c-1d77ae4bd714","order_by":1,"name":"Mackenzie Senior","email":"","orcid":"","institution":"NOSM University","correspondingAuthor":false,"prefix":"","firstName":"Mackenzie","middleName":"","lastName":"Senior","suffix":""},{"id":374645359,"identity":"e99b4b99-515a-4cee-b162-1121b564169a","order_by":2,"name":"Adam Bignucolo","email":"","orcid":"","institution":"Health Sciences North","correspondingAuthor":false,"prefix":"","firstName":"Adam","middleName":"","lastName":"Bignucolo","suffix":""},{"id":374645360,"identity":"d8f3ec2e-0e26-4028-889a-98bb69010d52","order_by":3,"name":"Holly Sarvas","email":"","orcid":"","institution":"Health Sciences North","correspondingAuthor":false,"prefix":"","firstName":"Holly","middleName":"","lastName":"Sarvas","suffix":""}],"badges":[],"createdAt":"2024-11-05 04:08:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5391952/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5391952/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":74986503,"identity":"2d25e083-9b2a-4894-aab9-0404b86b64f2","added_by":"auto","created_at":"2025-01-29 06:16:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":708180,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5391952/v1/88abd3a2-c206-4c79-b019-5f035abd1dda.pdf"},{"id":69375924,"identity":"5e54ba51-3465-4082-bf42-8cd8ab8982d1","added_by":"auto","created_at":"2024-11-19 17:09:09","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":546794,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile1CoDebriefingChecklist.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5391952/v1/f7adca7fe1f15cd5026335a4.pdf"},{"id":69375125,"identity":"640e2d58-4998-4362-96bf-4e16dbaa5a6c","added_by":"auto","created_at":"2024-11-19 17:01:09","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":31261,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile2InterprofessionalCodeBlueTrainingParticipantEvalFormAug20212.docx","url":"https://assets-eu.researchsquare.com/files/rs-5391952/v1/4c72f630599a362a8ae27db7.docx"},{"id":69375923,"identity":"a7e83156-753a-43f9-ae9f-1234358c06e5","added_by":"auto","created_at":"2024-11-19 17:09:09","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":20237,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile3LiteraturereviewEffectivelyCodebriefinganInterprofessionalTeaminaSimulationContextASystematisedReviewandQualitativeStudy.docx","url":"https://assets-eu.researchsquare.com/files/rs-5391952/v1/66fed44c57d7e77c422c37cf.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectively Co-debriefing an Interprofessional Team in a Simulation Context: A Systematised Review and Qualitative Study","fulltext":[{"header":"Background","content":"\u003cp\u003eThe use of simulations can enhance participants\u0026rsquo; skills to improve their patient care in real-life scenarios.\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Interprofessional education (IPE) in healthcare emphasises collaborative practices that involve two or more healthcare professionals working together to improve patient care quality.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Thus, practising simulated resuscitations in an IP setting prepares healthcare providers for realistic scenarios, incorporating collaboration and communication skills between professionals.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e IPE can also lead to greater technical skills through role clarification between professionals and the reduced use of equipment.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDebriefing facilitates the growth of healthcare learners by reflecting on their performance and applying it to future practice.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e There are different ways to debrief, however, no debriefing method is widely accepted as an optimal practice.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e In an IP debrief, professional power discrepancies can negatively affect communication and collaboration between debriefers and team members.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e It is imperative that debriefers use a collaborative approach to create an environment conducive to participant growth. This can be achieved by using IP co-debriefers, or two or more debriefers from different professions.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eUsing IP co-debriefers allows for deeper discussion with specialised knowledge, which targets the IP participants as a heterogeneous group.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e However, the IP co-debriefer approach comes with challenges when attempting to consolidate participants\u0026rsquo; knowledge as a partnership with diverse opinions and experiences.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Previous research has examined debriefing an IP team using a single debriefer;\u003csup\u003e\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e or IP co-debriefers in a pre-licensure group.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan additionalcitationids=\"CR19 CR20 CR21\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e There is limited literature exploring IP co-debriefing in a team of IP post-licensure professionals. While select variables have been explored including participant performance,\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e debriefing challenges and recommendations,\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e videoconference,\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e the use of a written tool,\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e and power dynamics,\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e there are no clear recommendations on how to successfully co-debrief a post-licensure IP team following a simulation. This study therefore aimed to do the following:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIdentify strategies for IP co-debriefers to use that are beneficial to debriefing a post-licensure IP team following a simulation.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIdentify solutions to common challenges presented to IP co-debriefers while debriefing a post-licensure IP team following a simulation.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study had two approaches: a systematised literature review (Additional File 3) and a collection of qualitative data from post-simulation IP debriefing sessions. The results from the literature review were used to inform and compare the data gathered from the debriefing sessions. A summary of the systematised review can be found in Appendix \u003cspan refid=\"Sec14\" class=\"InternalRef\"\u003eA\u003c/span\u003e.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResearch Paradigm\u003c/h2\u003e \u003cp\u003eThis qualitative study focuses on interpreting human experiences in words; thus, a combination of constructivist and grounded theory research paradigms was used.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Constructivism is a philosophical orientation that suggests that reality is dependent on a person\u0026rsquo;s perceptions and that reality and fact are determined by experiences.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e This approach is applicable to the research question posed, as the goal is to determine strategies to effectively debrief an IP team via written and verbal feedback and experiences. Grounded theory generates theory from data; the data relevant to the research purpose emerges through analysis.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e In this study, the identified themes surfaced from the data collected.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Design\u003c/h3\u003e\n\u003cp\u003e The study was conducted at a tertiary care hospital located in Northern Ontario and approved in November 2021 by the Health Sciences North (HSN) Research Ethics Board (REB) (project number 21\u0026ndash;040). Four simulation cases were created for this study. Each case was repeated three times with a control case in between, running from December 2021 to December 2023. A total of 12 simulations were hosted in this period, since some cases were not run due to participant sickness and unavailability. Each case included variable medical complexities that resulted in a cardiac arrest and the need for resuscitation. The participants were pre-briefed on the simulation and research components of the study. Following the pre-brief, participants engaged in a 20-minute simulation, where the debriefers used an original debriefing reference checklist (Additional File 1) to keep track of the case events, participant roles, and organise the topics needed to debrief. After the simulation, the debrief was hosted for 40 minutes by two trained IP debriefers, who were physicians, registered respiratory therapists (RRTs), or registered nurses (RNs). At minimum, a physician and non-physician hosted the debrief. A co-debriefing checklist formulated by Cheng et al.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e was used to ensure a thorough pre-to-post debriefing process. During the debrief the PEARLS framework, developed by Eppich and Cheng\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e was used as a tool to guide the debrief. After the simulation participant debrief, the participants completed a Likert-scale survey with open-ended questions on the simulation and the debrief (Additional File 2). Another 20-minute debrief-the-debriefer session occurred while the participants completed the surveys. During this time, the debriefers discussed strategies that worked, challenges that arose, and future changes that could be made, while a researcher scribed the discussion. The data collected from the debrief-the-debriefer sessions, as well as the data from the participant surveys were used for thematic analysis.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSampling\u003c/strong\u003e \u003cp\u003eThe simulation participants were included on a voluntary basis and recruited via convenience and snowball sampling by morning announcements or sign-up forms in each respective department. The participants for each simulation included two critical care RNs (Emergency Department and Intensive Care Unit), one RRT, and two physicians, usually Emergency Medicine, Internal Medicine, or Anaesthesia residents, although occasionally supplemented with Emergency or Intensivist physicians. Purposeful sampling was used for the debriefing participants as they were known as experienced debriefers through previous simulations and were contacted for voluntary participation in the study. Each simulation used different debriefers on the basis of availability. As this phenomenological study examines experience, feedback, and opinions from the expert debriefers, purposive sampling is appropriate.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData collection\u003c/strong\u003e \u003cp\u003eThe data collected were a mix of four different sets. All data were collected in Microsoft Word documents and saved to a BitLocker-protected hard drive, which was password-protected and locked in the simulation laboratory. The first data set consisted of notes from the debrief-the-debriefer sessions, the second set was a summary of each debrief-the-debriefer session, typed by the same researcher who scribed the debrief-the-debriefer data, and the third data set included qualitative data from the participant surveys. The fourth data set occurred 20 months after the project started as a method of ensuring data saturation. This data set consisted of a two-hour-long, in-person, recorded and transcribed debrief-the-debriefer session, where the study debriefers were asked a set of questions on their experiences.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eThematic Analysis\u003c/strong\u003e \u003cp\u003eQualitative data are best explored by categorising and recognising patterns to describe the phenomenon.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e Thus, a theoretical thematic analysis was conducted on the basis of a modified Braun and Clarke\u0026rsquo;s 6-Step Framework.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003eIn the first phase, the goal is to become familiar with the data. Two authors read through the data sets twice prior to coding. All data not related to debriefing were removed. The second phase included generating preliminary codes based on related concepts. The third phase involved searching for themes, which was performed simultaneously with the second phase. In the fourth \u0026ldquo;reviewing themes\u0026rdquo; phase, both authors worked together and shared their initial themes, which were broken down into subthemes, grouped, and eliminated. This was transcribed to another document with descriptions for each theme, concluding the fifth phase, \u0026lsquo;defining and naming themes\u0026rsquo;. If subthemes were included, they were defined and incorporated into the broad themes. Finally, the \u0026lsquo;producing the report\u0026rsquo; phase was completed and is described in the \u003cspan refid=\"Sec5\" class=\"InternalRef\"\u003eresults\u003c/span\u003e section below.\u003c/p\u003e \u003cp\u003eA similar approach was used to conduct the thematic analysis from the final debrief-the-debriefer session; however, for this data set, Atlas.ti was used for manual coding and theming.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFive broad themes with nine subthemes were established. The themes and their subheadings are as follows: Effective Communication (use of specific questioning, discussion generation, empowering facilitators, and framework), Knowledge Gaps (specific education, empowering facilitators), Therapeutic Milieu (empowering participants, framing discussion, facilitator confidence/comfort), Effective Physical Structure, and Suggesting Tool Use. The themes can be found in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, at the bottom of the manuscript.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes from the post-simulation IP debriefing data and survey data.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBroad theme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubtheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of subtheme\u003c/p\u003e \u003cp\u003eoccurrences\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExample\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eEffective communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUse of specific questioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUsing specific wording when asking a question directly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ldquo;What strategies could you have utilised to get help from your team?\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiscussion generation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePhrases or strategies that allow participants to reflect verbally\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ldquo;How did that feel?\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmpowering facilitators\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGiving the debriefers strategies and support to confidently lead a debrief\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ldquo;Novice staff need more support and orientation\u0026rdquo; \u0026ldquo;Using the phrase \u0026lsquo;I am curious why\u0026hellip;?\u0026rsquo; to navigate intimidating participants\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFramework\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUsing a specific framework to follow to guide the debrief\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePEARLS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eKnowledge gaps\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpecific Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe use of specific tools, policies, or guidelines to help support specific debriefing topics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ldquo;Could have used the ACLS algorithm cognitive aid more directly in the debrief\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEducating facilitators\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEnsuring facilitators are educated and credible on the subjects they are teaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ldquo;Review ACLS \u0026ndash; focused inquiry in reflection to ACLS algorithm\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eTherapeutic Milieu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmpowering participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo be able to contribute for a meaningful and safe debrief\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ldquo;Leave on positive note and ask learners for their key take away points\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026ldquo;Put yourself in vulnerable position to support participants and normalise their feelings\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFraming discussion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHow phrases are used versus what phrases are used\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ldquo;I agree\u0026hellip;. here\u0026rsquo;s what went well\u0026rdquo;\u003c/p\u003e \u003cp\u003eUse \u0026ldquo;how did that feel?\u0026rdquo;; avoid \u0026ldquo;how do you feel that went?\u0026rdquo; or \u0026ldquo;how did you think you did?\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFacilitator confidence/ comfort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStrategies that were used to increase the debriefer\u0026rsquo;s belief that they are capable of successfully debriefing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ldquo;Providing the debriefers an opportunity to practise their thoughtful questioning during the safe and supportive environment of this \u0026lsquo;debrief the debriefer session\u0026rsquo;\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026ldquo;Change your chair position, shift your papers, stand up etc\u0026hellip;. change your physical position to divert the conversation in a new direction\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026ldquo;Playing on facilitator strengths\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEffective Physical Structure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWays that the physical environment helped create a space conducive to debriefing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePositioning in a triangle\u003c/p\u003e \u003cp\u003eHaving multiple IP debriefers\u003c/p\u003e \u003cp\u003eHaving more time for debrief\u003c/p\u003e \u003cp\u003eDebrief-the-debriefer session\u003c/p\u003e \u003cp\u003ePre-brief discussion framing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecific Tool Use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe use of specific tools to complement the debrief\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUse of videos during debrief\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFrom the final debrief-the-debriefer session, three broad themes with 22 subthemes were officially established. The themes and their subheadings are as follows: Technique (circling back, discussion generation, framing discussion, nonverbal cues, learned-centred, positive reinforcement, safety, framework), Facilitator (coaching, debriefer feedback, mentorship, training, empowering facilitators, expertise, internal facilitator feedback, reflection), and Participant (curious intentions, positivity, empowering participants, interdisciplinary, personal experience, teamwork). These themes are not tabled since they are adjuncts to the discussion.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e The themes and subthemes are discussed relative to the literature from the data collected from the debriefing sessions.\u003c/p\u003e\n\u003ch3\u003eEffective communication\u003c/h3\u003e\n\u003cp\u003e The overarching theme, \u0026lsquo;Effective Communication\u0026rsquo;, is used to break down ways in which the debriefers noticed phrases used to allow participants to reflect to self-guide the debrief.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eUse of specific questioning\u003c/strong\u003e \u003cp\u003eIn the case where the team leader may require assistance from their team members, the question \u0026ldquo;What strategies could you have utilised to get help from your team?\u0026rdquo; was asked. This direct, yet open-ended question allows participants to reflect on a situation with a specific goal in mind. This specific questioning method avoids neutral statements by debriefers that can confuse participants and fail to address the learning objectives.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Another specific question that was frequently used is \u0026ldquo;If you had to turn back the clock, what or how would you have done differently?\u0026rdquo;. This allowed the participants to reflect on the key learning points that occurred during the simulation. However, direct questioning may not always benefit participants. For example, if a participant incorrectly uses the ACLS algorithm, directly asking them the steps of the algorithm may compromise the learner\u0026rsquo;s psychological safety. Specific questioning with more sensitive subjects could be beneficial or harmful depending on the context and perception.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e However, in the right context, specific questioning generates discussion, avoids confusion, and can be useful for the participant\u0026rsquo;s learning outcomes.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDiscussion generation\u003c/strong\u003e \u003cp\u003e\u0026ldquo;Discussion generation\u0026rdquo; encompasses any phrase that gives participants the opportunity to speak in a psychologically safe space. For example, using the beginning phrase \u0026ldquo;how did that feel?\u0026rdquo; allows participants to delve into their initial thoughts without immediately explaining the rationale. This phrase is used in the \u0026lsquo;Reactions Phase\u0026rsquo; of the PEARLs framework where all comments are held until each participant has a chance to express how they feel.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e The use of open-ended questions allows participants to reflect on their actions and answer questions on their own perceptions.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Finally, an important discussion-generating point is to be more of a moderator than a contributor. A tip for learner-centred debriefing is to direct any questions asked back to the group for discussion.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e This creates less of a lecture-style debrief and more of a collaborative approach. The discussion is particularly generative in debriefs with post-licensure IP participants who have extensive knowledge that they can share between each other.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Furthermore, a debriefer who directly informs the participants of their performance removes the opportunity for them to direct the learning process.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e There is an inverse relationship with facilitator contributions and learner engagement, and learner engagement increases by asking questions themselves.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Eventually, if the participants are unable to come to a conclusion about the question, the facilitator can contribute.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEmpowering facilitators\u003c/strong\u003e \u003cp\u003eThere are many strategies to help debriefers feel less intimidated by participants, which was a challenge in this study. First, debriefers should avoid debating, which may further lead to a power imbalance.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e To manage the intimidation, ask the participant \u0026ldquo;I am curious why\u0026hellip;?\u0026rdquo; in a genuine tone to encourage understanding of the participant\u0026rsquo;s perspective. This may be helpful for non-physician debriefers, since the stereotype that physicians are academically stronger than other faculty members can be a barrier to IP contribution.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e It was evident in this study that newer debriefers seek more direction when debriefing. Some proposed strategies for beginner debriefers are to understand the importance of debriefing, apply related debriefing tools, and create a psychologically safe space for participants to increase their contribution.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e Once these skills are solidified, the debriefer can apply their knowledge to optimise co-facilitation. Overall, the theme \u0026ldquo;empowering facilitators\u0026rdquo; coincides with two other themes, \u0026ldquo;facilitator education\u0026rdquo; and \u0026ldquo;facilitator confidence/comfort\u0026rdquo; which differ slightly depending on the context.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFramework\u003c/strong\u003e \u003cp\u003eA written framework was used to guide the debriefs in this study (PEARLS).\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Using PEARLS in the debrief-the-debriefer sessions ensured that minimal learning points were missed. Using a framework is useful for novice debriefers, who may require more support.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Additionally, using a framework provides educational support for other IP members who are debriefing physicians, who potentially have more training than their allied health counterparts do. As the debriefer gains experience, it is suggested to follow the framework but modify it based on the specific needs of the participants and context.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Furthermore, the literature suggests that using a framework while debriefing significantly improves learning outcomes for participants.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e The use of a written tool while debriefing shifts the focus from the facilitator to learner-self assessment.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e The goal is to allow participants to guide the discussion in a reflective manner.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cb\u003eDebrief-the-debriefer session\u003c/b\u003e: During the debrief-the-debriefer session, the subthemes of \u0026ldquo;discussion generation\u0026rdquo; and \u0026ldquo;framework\u0026rdquo; were both highlighted. Debriefers reflected on the subtheme \u0026ldquo;Framework\u0026rdquo;, acknowledging the importance of using an evidence-based outline during the debrief session and guiding debriefers to remain systematic in their debrief. One debriefer commented on this: \u0026ldquo;I think that brings on the importance of when you do this, [have] a game plan. You know, we showed up to these scenarios with the objectives for the learners, but [also with] objectives for the debriefers\u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge Gaps\u003c/h2\u003e \u003cp\u003e The broad theme \u0026lsquo;knowledge gaps\u0026rsquo; is used to address strategies that are effective in closing participants\u0026rsquo; knowledge gaps in specific domains, such as ACLS guidelines and specific equipment challenges.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSpecific education\u003c/strong\u003e \u003cp\u003e The subtheme \u0026ldquo;specific education\u0026rdquo; refers to the use of policies or guidelines to help support specific topics during the debrief. For example, one tool that is commonly used is the American Heart Association (AHA) ACLS algorithm.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e During the debrief-the-debriefer sessions, the ACLS algorithm could have been used as a cognitive aid for the team during the debrief to solidify participants\u0026rsquo; visual needs. Additionally, there were challenges associated with specific equipment, particularly the portable defibrillators. Rather than solely discussing these challenges, it was suggested that the equipment be brought into the debrief to be practised utilising it. Critical performance issues that arise must be a priority of discussion.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e Mistakes made when equipment is used must be addressed to prevent future errors. Furthermore, if mistakes are made in the ACLS algorithm or other critical care interventions, it is key to delve into these mistakes in a sensitive, inquisitive manner.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Approaching sensitive conversations with a neutral approach can be confusing for the participants and should be addressed cautiously but directly.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Facilitators should be educated on the content in which the simulation is about, which will be elaborated on in the next section.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cb\u003eEducating facilitators\u003c/b\u003e. A point that emerged from the data was that debriefers should have a strong understanding of the material on which they are debriefing. If the simulation requires following the ACLS algorithm, the debriefers should have a deep understanding of this, or else use the cognitive aid during the debrief.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e However, participants value debriefing credibility just as they value clinical credibility.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e IP co-debriefing is an effective way to mediate this. Experienced healthcare professionals can be trained in debriefing courses and gain experience in smaller debriefs prior to co-debriefing an IP session. In this study, novice debriefers were offered a two-and-a-half hour debriefing course highlighting co-debriefing and IPE strategies. Nonetheless, this study\u0026rsquo;s findings did not highlight any issues with the credibility of the debriefers but rather the energy the debriefers emitted. One participant commented that \u0026ldquo;more enthusiasm from [the] facilitator would create a better space for discussion\u0026rdquo;. Correspondingly, debriefers should demonstrate motivation and enthusiasm to engage the participants in the discussion.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDebrief-the-debriefer session\u003c/strong\u003e \u003cp\u003eIn the Facilitator theme, several subthemes relate to the simulation data collected above. For example, training, expertise, mentorship, reflection and coaching were all subthemes that highlighted qualities that benefit the debriefer. Training and coaching refer to specific training as a debriefer and receiving guidance from experienced debriefers. \u0026ldquo;There was a strength [in] being able to debrief the debriefer in a formal manner\u0026hellip; [it was] pretty critical to getting people [to] feel confident. And\u0026hellip; practising the road map\u0026hellip; following the framework for [de]briefing and being able to try new things\u0026rdquo;\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTherapeutic Milieu\u003c/h3\u003e\n\u003cp\u003eThe theme \u0026lsquo;therapeutic milieu\u0026rsquo; is used to discuss strategies that create a safe space for participants.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEmpowering participants\u003c/strong\u003e \u003cp\u003e This subtheme highlights the need for participants to feel safe, confident and able to contribute to meaningful discussion during the debrief. An interesting point from the data was that team members who were newer in their profession were not comfortable giving feedback to the group because they were feeling inexperienced. Holmes and Mellanby\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e noted that anxiety was heightened in junior staff when they were asked to speak in front of colleagues, especially when there were more senior staff. A recommended strategy was to use specific questioning with caution directed at junior learners.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e If they are hesitant to answer, changing the focus to another participant is wise to maintain a psychologically safe learning space. Specifically, disclosing the debriefer\u0026rsquo;s own uncertainties and being vulnerable to participants was an effective strategy in this study. A specific phrase that was used to normalise a participant\u0026rsquo;s feelings was \u0026ldquo;uncertainty is a really uncomfortable feeling for me\u0026rdquo;. Normalising a participant\u0026rsquo;s feelings when an emotional situation arises during the debrief creates a psychologically safe learning environment for participants and is more likely to create the desired change.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e Moreover, providing validation does not imply that the debriefer agrees with the participant\u0026rsquo;s course of action, however, it does confirm that the debriefer is listening and that the participant\u0026rsquo;s perspective is important.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFraming discussion\u003c/strong\u003e \u003cp\u003eFraming the discussion refers to \u003cem\u003ehow\u003c/em\u003e something is said, not \u003cem\u003ewhat\u003c/em\u003e is being said. For example, in this study, careful caution was used during the initial \u0026ldquo;reaction\u0026rdquo; phase to say, \u0026ldquo;How did that feel?\u0026rdquo; rather than \u0026ldquo;How do you think you did?\u0026rdquo;. When the latter was used, the participants often proceeded to discuss their perceived mistakes. A safe learning space, which is enhanced by positive reinforcement, is necessary for development.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e A method used in this study to reinforce a positive learning environment was to encourage positive comments in each participant's performance. For example, if a participant discusses their contributions to the simulation, the debriefer can respond with \u0026ldquo;I agree\u0026hellip; Here's what went well\u0026rdquo;. However, mistakes must also be discussed but should be viewed as learning opportunities rather than negative aspects of the simulation.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e Practical mistakes are commonly made during simulation, so it is important to pre-brief prior to the simulation and ensure that each participant is aware that the simulation and debrief are safe learning spaces and that every participant is believed to be there for growth and development.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eCaution should be exercised when framing the discussion, as sometimes the way a debriefer says a phrase may not frame the discussion how they intended. For example, in one of this study\u0026rsquo;s cases, the question \u0026ldquo;Do you think it was your experience that led you to think you did not need to designate roles?\u0026rdquo; was asked to an IP participant. The intent was to allow the participant to reflect on the ACLS algorithm and highlight the use of their IP team members; however, the debriefer\u0026rsquo;s question was answered by themself. A more suitable frame would be \u0026ldquo;I am curious about your thought process when you are deciding which direction to take with the patient\u0026rdquo;. This allows the participants to run through their decision-making process and ask for clarification if needed. Overall, discussions should be framed positively to enhance psychological safety and clearly to avoid confusing the participants.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFacilitator confidence/comfort\u003c/strong\u003e \u003cp\u003e Facilitator confidence and comfort refer to strategies that are used to increase the debriefer\u0026rsquo;s belief that they are capable of successfully debriefing and benefitting the participant\u0026rsquo;s learning needs. For example, debriefers were given the opportunity to participate in two-and-a-half hour debriefer training to promote confidence in debriefing techniques. Then, in the debrief-the-debriefer session, the facilitators practised debriefing on each other to receive feedback on how the participant may have perceived the question. The literature highlights that co-debriefing can be used to enhance faculty development through peer feedback.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Additionally, in the debrief-the-debriefer session, co-debriefers can discuss the challenges of the simulation to benefit their own learning needs for the next debrief. Another display of facilitator confidence is the use of body language, which displays focus from the debriefer on to the participant.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e In this study, shifting papers or changing positions were the strategies used to divert the participants\u0026rsquo; attention. A last example of increasing a debriefer's confidence is to play on the facilitator strengths. For example, if one of the debriefers is a RRT, discussing the airway during the debrief will be a comfortable topic in which the debriefer is well versed. This is an advantage of IP co-debriefing, as having different types of expertise combined provides a larger scope of specialised knowledge to deliver to participants.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDebrief-the-debriefer session\u003c/strong\u003e \u003cp\u003eFinally, in the debrief-the-debriefer data, the subtheme \u0026ldquo;empowering participants\u0026rdquo; was the dominant theme. The debriefers commented on the importance of allowing the participants to lead the discussion. \u0026ldquo; \u0026hellip; [you have to] try to enable them to come up with their own conclusion and thoughts\u0026rdquo;. \u0026ldquo;Mind you, I don\u0026rsquo;t actually think [the] debriefer\u0026rsquo;s role is to give any feedback. I think it\u0026rsquo;s to elicit feedback from the team\u0026rdquo;.\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eEffective physical structure\u003c/h3\u003e\n\u003cp\u003eThe theme \u0026lsquo;Effective physical structure\u0026rsquo; is used to describe ways in which the physical environment helps create space and time conducive to debriefing. In this study, the physical environment was optimised by debriefers arranged in a triangular shape with three debriefers or across a table with two debriefers. This allowed the debriefer to view each other\u0026rsquo;s nonverbal cues.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Next, having multiple IP debriefers was necessary for the purpose of this study; however, it is very beneficial to have multiple debriefers as this provides more than one area of specialty to benefit the participants.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e The need for more time during the debrief was noted by two participants. The debriefs in this study were 40 minutes, which is twice as long as the simulation. There are no clear guidelines on how long a debrief should last; however, a common length of time for debriefing is two to three times the length of the simulation, with some suggestions saying five-times the length of the simulation.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAdditionally, the debriefers in this study mentioned that having a debrief-the-debriefer session was beneficial for overcoming challenges and improvements for future debriefs. Finally, framing the discussion with a pre-brief mention of confidentiality, encouraging participation, and ensuring the setup for psychological safety of the participants allows the debrief to begin smoothly with learning objectives identified and ready to be discussed.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSuggesting tool use\u003c/h2\u003e \u003cp\u003eThe \u0026ldquo;Suggesting tool use\u0026rdquo; theme is used to describe specific tools that debriefers agreed may be beneficial for future debriefs. In this study, the use of video for the simulation was mentioned three times. There is literature that supports the use of video during a debrief; however, there is no consensus on whether it affects participants\u0026rsquo; learning outcomes.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e Some benefits of video include: increasing selected behaviours in the future, enhancing reflective reasoning, and allowing for on-the-spot reflection.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e Overall, the use of video during a post-IP-simulation debrief requires further research to examine its impact.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eOne limitation of this study is that the qualitative data gathered to identify effective methods of debriefing were collected by the debriefers. Collecting data from the participants would provide valuable insight into what changes should be made in the debriefing process to suit the needs of the participants.\u003c/p\u003e \u003cp\u003eThe literature review was limited to PubMed and CINAHL. For a more scoping review, Google Scholar and other databases could have been used. In future research, PRISMA guidelines could be followed for a systematic review.\u003c/p\u003e \u003cp\u003eSome of the simulations were cancelled because of sickness and low participation. If all simulations were performed as planned, more data could have been collected from the debriefing-the-debriefer meetings. Future research could examine the factors affecting simulation participation and this could be implemented in future simulations for optimal participant retention.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOverall, this paper intended to highlight effective methods and strategies that the IP faculty could use to effectively debrief an IP team after a Code Blue simulation. Multiple strategies were identified through a review of the literature and data collected from the simulations hosted for this study.\u003c/p\u003e \u003cp\u003eSome suggestions agreed upon by the literature and this study\u0026rsquo;s data include and are not limited to using an IP learner-centred approach with combined open-ended questions and specific questioning, using specific frameworks to guide the debriefing (such as PEARLS, created by Eppich \u0026amp; Cheng)\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e, and using IP co-debriefers who are educated in the topic of simulation as well as trained in debriefing.\u003c/p\u003e \u003cp\u003e Further research should examine IP co-debriefing strategies from the perspective of the participants, rather than the debriefers, to add to the body of knowledge from the debriefing perspective. Incorporating both aspects of debriefing would complete a global perspective and suit the needs of all members involved in the debriefing.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eE.M wrote the main manuscript, prepared Table 1, Appendix A, and Additional File 4, and performed the thematic analysis of the qualitative study and literature review with M.S. A.B. organized and managed the project from start to finish, with assistance from H.S. H.S. and A.B. collected the data for the qualitative study and contributed largely to edits. All authors reviewed the manuscript and approved it before submission.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eDr. Nicholas FortinoKyle Mispel-BeyerChristine BickRenee FillierKayla Noble\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due to confidentiality reasons that would compromise individual privacy, but are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHolmes C, Mellanby E. Debriefing strategies for interprofessional simulation\u0026mdash;a qualitative study. Advances in Simulation. 2022;7(1):18. 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The authors implemented a systematised review that enacted search strategies, multiple reviewers, columns, and specific inclusion and exclusion criteria to gather the latest information on IP debriefing.\u003c/p\u003e \u003cp\u003eThe Pubmed and CINAHL databases were used for the literature review. The search terms for each database were Debrief* AND (Interprofessional or multidisciplinary or interdisciplinary) AND simulation, which were informed by the Holmes and Mellanby review.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The inclusion criteria for the papers were any full-text, English language article that included IP healthcare-based simulation and debriefing, whereas the exclusion criteria were non-full text articles, articles not in the English language, non-IP participants and single debriefers. Subset analyses were performed to differentiate between pre-licensure participants and post-licensure professionals to identify differing themes.\u003c/p\u003e \u003cp\u003eA total of 58,406 items were identified from the database via the search terms. After the title review, 215 items remained. After the abstracts were reviewed, 30 articles were identified for full-text review. Three articles were excluded from the full-text review because they did not include IP participants or co-debriefers. Eight articles were initially included for secondary review but were ultimately excluded because they did not meet the needs for either IP simulation or co-debriefing. After thoughtful review of the articles in the context of the inclusion and exclusion criteria, 15 articles were included since they had most of the research components, and the decision was made to include the pre-licensure and post-licensure subset analyses. The entire literature review can be found as Additional File 3 labelled \u0026ldquo;Literature Review\u0026rdquo;.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Debriefing, Simulation, Interprofessional, Post-licensure learning, Continuing education","lastPublishedDoi":"10.21203/rs.3.rs-5391952/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5391952/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDebriefing after an interprofessional (IP) simulation is key to participant learning. Incorporating IP co-debriefers mitigates power discrepancies and increases collaboration between debriefers and participants to optimise learning. Nevertheless, there are challenges that come with co-debriefing an IP team following a simulation, with limited recommendations for managing these challenges. This study aims to identify methods for how IP faculty can effectively debrief a post-licensure IP team following a Code Blue simulation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e This study conducted both a systematised literature review and a theoretical thematic analysis of post-simulation IP debriefing sessions. The search terms for PubMed and CINAHL were Debrief* AND (Interprofessional or multidisciplinary or interdisciplinary) AND simulation, with a date range of 2012\u0026ndash;2022. Thirty articles were identified by title and abstract review, with 16 articles meeting the inclusion criteria. The thematic analysis was derived from post-simulation IP debriefing data collected from 12 simulation IP debriefs. These data included debrief-the-debriefer notes, participants\u0026rsquo; post-debrief surveys, and a final debrief-the-debriefer session after all simulation sessions were complete.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFive broad themes with nine subthemes were established by correlating the literature review findings alongside the post-simulation IP debriefing data and survey data: Effective Communication (use of specific questioning, discussion generation, empowering facilitators, and framework), Knowledge Gaps (specific education, empowering facilitators), Therapeutic Milieu (empowering participants, framing discussion, facilitator confidence/comfort), Effective Physical Structure, and Suggesting Tool Use.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eMultiple strategies useful for IP co-debriefing were found, such as the use of an IP learner-centered approach with combined open-ended questions and specific questioning; the implementation of specific frameworks to guide the debrief; and the provision of IP debriefers educated in both simulation cases and debriefing. This study contributes to the research by acknowledging the uniqueness of IP co-debriefing compared with other debriefing models, and identifying effective strategies for IP co-debriefers to use in a post-licensure IP debrief. Further research should explore in-depth reviews of faculty debrief-the-debriefer sessions to inform a guiding framework for future debriefers.\u003c/p\u003e","manuscriptTitle":"Effectively Co-debriefing an Interprofessional Team in a Simulation Context: A Systematised Review and Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-19 17:01:04","doi":"10.21203/rs.3.rs-5391952/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"567a29de-a363-4078-9030-6cc6cd73de66","owner":[],"postedDate":"November 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-29T06:08:41+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-19 17:01:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5391952","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5391952","identity":"rs-5391952","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}