How to debrief teamwork interactions: using circular questions to explore and change team interaction patterns

Teamwork and its components (e.g., leadership, communication) are typical content of learning objectives in simulation-based training [4, 5, 11–20]. This is important because effective teamwork has been linked to patient safety [21, 22]. Some teamwork components are attitudinal such as team orientation (i.e., preference for working with others) while others are behavioral and process-like such as leadership and mutual performance monitoring [23]. Simulation-based training mostly addresses the latter. Team process is defined as “members’ interdependent acts that convert inputs to outcomes through cognitive, verbal, and behavioral activities directed towards organizing taskwork to achieve collective goals” (p. 357) [24]. From our view, this team process, the interdependency of team members’ actions, and their importance for clinical performance are not yet fully explored during debriefings.

First, discussions during debriefings tend to be focused on team members’ individual behaviors and frames about their individual actions [25]. This focus is important for uncovering the reasoning behind individual actions [9, 26]. Yet, it is potentially not sufficient for surfacing team dynamics because it does not yet allow for uncovering mutual dependency of behavior or self-reinforcing behavior patterns. Exploring these patterns would be beneficial: recent research has shown that it is particularly the pattern of behaviors among team members that discriminate higher from lower performing teams [27–32]. For example, during inductions of general anesthesia, higher-performing teams showed more talking aloud patterns than average-performing teams. [27] Also, teams engage in solution-oriented as well as complaining-oriented sequential patterns which are associated with positive and negative team mood, respectively [33, 34]. So far, these team interaction patterns have rarely been explicitly uncovered, explored, or altered in debriefings, resulting in missed opportunities for new information, perspectives, and change.

Second, by focusing on individual thought and feeling processes rather than on team interactions, instructors might overestimate the individual’s capacity and underestimate the influence of the context on the individual. Thus, we make, as Ross [35] described, the fundamental attribution error: we overestimate the individual learner’s disposition and personality and underestimate their environment and situational dynamics. With respect to teamwork, this means that instructors might overestimate the linear causality of teamwork behaviors and underestimate the circular causality of behaviors, that is the mutual dependency of behaviors; a person’s behavior at one time is considered both effect and cause of the interactional partner’s behavior [36]. For example, while the assumption that the more internally willing individual team members were to speak up, the more effort they would put into actually speaking up would be based on linearity; the assumption that if team member A speaks up and team member B reacts with verbal appreciation, team member A might feel encouraged to speak up in future teamwork would be based on circularity. So far, circularity is rarely systematically explored during debriefings, missing an essential element of teamwork.

Third, using linear rather than circular assumptions, we tend to underestimate the meaning and messages of feelings, thoughts, and actions within the team as system. For example, by asking

Why didn’t you speak up? – (Learner: “I don’t know.”)

not much is yet explored about the potential function of not speaking up for the system such as preserving hierarchy within the team, maintaining responsibilities or respecting sub-team territory [3, 18]. The resulting lack of new, different information tends to have a conservative effect on the learner, which may implicitly validate preexisting beliefs (e.g., that speaking up is too risky) [2]. As a further result, instructors may stop exploring an issue in more detail because they feel that they have understood “enough”. This phenomenon has been called the confirmation bias, that is, seeking or interpreting information in a way that confirms existing beliefs, expectations, and hypotheses [37]. Instructors are then at risk to develop solutions that do not fit the (not yet comprehensively discovered) problem [38].

In sum, we submit that circular interactional patterns within healthcare teams and their importance for clinical performance should be explored more comprehensively during debriefings. We propose that by applying systemic thinking and asking circular questions, instructors can actively use debriefings to walk the talk of teamwork.