The Role of Debriefing in Simulation-Based Learning (2007)

The aim of this paper is to critically review what is felt to be important about the role of debriefing in the field of simulation-based learning, how it has come about and developed over time, and the different styles or approaches that are used and how effective the process is. A recent systematic review of high fidelity simulation literature identified feedback (including debriefing) as the most important feature of simulation-based medical education.1 Despite this, there are surprisingly few papers in the peer-reviewed literature to illustrate how to debrief, how to teach or learn to debrief, what methods of debriefing exist and how effective they are at achieving learning objectives and goals. This review is by no means a systematic review of all the literature available on debriefing, and contains information from both peer and nonpeer reviewed sources such as meeting abstracts and presentations from within the medical field and other disciplines versed in the practice of debriefing such as military, psychology, and business. It also contains many examples of what expert facilitators have learned over years of practice in the area. We feel this would be of interest to novices in the field as an introduction to debriefing, and to experts to illustrate the gaps that currently exist, which might be addressed in further research within the medical simulation community and in collaborative ventures between other disciplines experienced in the art of debriefing. THE BACKGROUND OF SIMULATION-BASED LEARNING Generally, in simulation-based learning, we are dealing with educating the adult professional. Adult learning provides many challenges not seen in the typical student population. Adults arrive complete with a set of previous life experiences and frames (“knowledge assumptions, feelings”), ingrained personality traits, and relationship patterns, which drive their actions.2 Adult learners become more self-directed as they mature. They like their learning to be problem centered and meaningful to their life situation, and learn best when they can immediately apply what they have learned.3 Their attitudes towards any specific learning opportunity will vary and depend on factors such as their motivation for attending training, on whether it is voluntary or mandatory, and whether participation is linked directly to recertification or job retention. Traditional teaching methods based on linear communication models (ie, a teacher imparts facts to the student in a unidirectional manner) are not particularly effective in adult learning, and may be even less so in team-oriented training exercises. The estimated half-life of professional knowledge gained through such formal education may be as little as 2 to 2.5 years.4 In the case of activities requiring both formal knowledge and a core set of skills, such as Advanced Cardiac Life Support, retention can be as little as 6 to 12 months.5,6 Much of the research in teaching adults indicates that active “participation” is an important factor in increasing the effectiveness of learning in this population.7 In fact, in any given curriculum, learning occurs not only by the formal curriculum per se but informally through personalized teaching methods (informal curricula), and even more so through embedded cultures and structures within the organization (hidden curricula).8 Adults learn best when they are actively engaged in the process, participate, play a role, and experience not only concrete events in a cognitive fashion, but also transactional events in an emotional fashion. The learner must make sense of the events experienced in terms of their own world. The combination of actively experiencing something, particularly if it is accompanied by intense emotions, may result in long-lasting learning. This type of learning is best described as experiential learning: learning by doing, thinking about, and assimilation of lessons learned into everyday behaviors. Kolb describes the experiential learning cycle as containing four related parts: concrete experience, reflective observation, abstract conceptualization, and active experimentation.9 Gibbs also describes four phases: planning for action, carrying out action, reflection on action, and relating what happens back to theory.10 Grant and Marsden similarly describe the experiential learning process as having an experience, thinking about the experience, identifying learning needs that would improve future practice in the area, planning what learning to undertake, and applying the new learning in practice.11 Simulation training sessions, which are structured with specific learning objectives in mind, offer the opportunity to go through the stages of the experiential cycle in a structured manner and often combine the active experiential component of the simulation exercise itself with a subsequent analysis of, and reflection on the experience, aiming to facilitate incorporation of changes in practice. Simulation offers the opportunity of practiced experience in a controlled fashion, which can be reflected on at leisure. Experiential learning is particularly suited to professional learning, where integration of theory and practice is pertinent and ongoing.11 In experiential learning, the experience is used as the major source of learning but it is not the only one. Both thinking and doing are required and must be related in the minds of the learner.10 The concept of reflection on an event or activity and subsequent analysis is the cornerstone of the experiential learning experience. Facilitators guide this reflective process. Indeed this ability to reflect, appraise, and reappraise is considered a cornerstone of lifelong learning. This is one of the core elements of training in healthcare articulated by the Accreditation Council on Graduate Medical Education in the United States.12 In practice however, not everyone is naturally capable of analyzing, making sense, and assimilating learning experiences on their own, particularly those included in highly dynamic team-based activities. The attempt to bridge this natural gap between experiencing an event and making sense of it led to the evolution of the concept of the “postexperience analysis”13 or debriefing. As such, debriefing represents facilitated or guided reflection in the cycle of experiential learning. ORIGINS OF DEBRIEFING IN SIMULATION-BASED LEARNING Historically, debriefing originated in the military, in which the term was used to describe the account individuals gave on returning from a mission.14 This account was subsequently analyzed and used to strategize for other missions or exercises. This military-style debriefing was both educational and operational in its objectives. Another connotation of debriefing developed out of the combat arena as a or as of and the of a event with the aim of and returning to the as as In this was on the of the to what This cognitive of events was in so that there was a The to describe what to account for the that and to new with other and the Another of debriefing, debriefing, was by and is used to a set of the is a to to review the and a aim is to and a event by and this and it debriefing, to in the to a event in an attempt to in the cognitive and emotional of what they there is that an of and its may be A may be for individuals and particularly as the is the for which it was Another for the term from psychology, and describes the means by which have in manner as of a are of the of the The of this required is to to and to any the experience may have of the have to the of debriefing in the educational of and assimilation of activities into their long-lasting learning. THE DEBRIEFING to as in debriefing, where there an of facilitators to set a for there is the for the in simulation-based learning to the within which will be to from experiences that might their sense of a debriefing process and learning experience, the must a where feel and to learn in a to be to their experiences in a and of the of the is which must be at all This is by a recent the to simulation-based learning, where the it a and and a a of the and their It is that the an of in the This is a when the the of the the learning the process of debriefing, and what it It is the where the learn what is of and the for their simulation-based learning experience. It is also a for the to on the learning and to that to the simulation with a set of frames and life previous experiences have an on how effective training will and to be into of the debriefing frames or of how a to the process, and The simulation and the debriefing to learning styles into This factor is by Kolb with the incorporation of the experiential learning cycle with learning learning styles are and with learning styles concrete experience and reflective to This of such as with this learning to in and with assimilating learning styles abstract and reflective They like and learners abstract and active They like to for and In a formal learning they to with new and learners concrete experience and active with this learn from experience. In formal learning, they to in to set to and to different approaches to a learning in individuals to and to the learning process by their learning styles to the its learning objectives. effective to individuals with a of different learning In experience, individuals may to the learning styles and are important factors for facilitators to when which of debriefing will be most for simulation It is also important for facilitators to learn about the of the whether are novices or are or are new to The can the experienced an opportunity to and learner and of the Despite many approaches to there are a of elements to most of identified elements in the debriefing process The elements are the and those to be It is for to be the if as their own The is the experience itself the and the is the this experience has on the The concept of is important adult learners to be by the and the event needs to be to their everyday to make an The and elements and of the out in a may be or the of a formal The is the experience will be seen on how has the debriefing. most debriefing approaches are the experience, more for formal with the event a of an event or through a review of educational experiences over a in the of A of models exist elements and describe debriefing or models all out of the natural of to experience an to on to it with and learn and based on the experience. reflection a learning experience might it is to be It may not at all if the of events on what has a formal debriefing the reflective process, both for and for the as a may of their own through phases: and a may have out of this particularly the active is in the event and is in their of what has The for the is to for to but the in a more The needs to the from the personalized account of what the to the more from the to the and the to the but must be not to the or make feel the core of the on reflection of the active experience and making sense of the there are that are to this reflection and assimilation to of the are described by many and are in different The of the debriefing models have many elements of the of identifying the of the experience, the that developed and the and which used in simulation is described by and describes this as the introduction to systematic reflection and analysis that the active component of the of what and of what in their own describes this as the of the events that The is described as identifying the in which was or for the the and of the analysis of the experience, where the they experienced the or the emotional and of the The identifying the different by and how they with the as a the and of the experience, which attempt to make with a of and everyday and of of the The of the debriefing be to the learning objectives and the and may be and or may be and within the such as a or a the debriefing the opportunity to how has a and what needs to be to bridge any gaps between and It also an opportunity to objectives with may be to on the evolution of the and to how the and in the simulation to life objectives or there are which of skills, or attitudes are to be and what be learned about of In the case of may be as in which of or new or of about such objectives is there are about how the have so must that from the events and their to those of the in the is a between making active and for their own learning they important and learning from of indicates that the of the have the to the of the simulation As the of the is in the best learning experience, training in is A of offer training in debriefing In to the formal education of such as the of expert with facilitators in their to and are A recent of in learning that facilitators felt that a formal training to debriefing, it was only with experience, and in the of an expert role that they more with the In the on the of facilitators as an important factor in the learning process and the of the and and in are of and that for the of and the to which the is in the debriefing process can depend on a of The of the experiential The of the The experience of the as individuals or a The of the with the simulation available for The role of in the curriculum, and if between the the facilitators to not as or but as This more may be most where the learning is Facilitators aim to guide and to The role of the student or in debriefing is from the role to one where the of are the ability to critically own what but what and it that and to actively to the learning process. on are a of methods of debriefing, and of that may be and debriefing in of with the the debriefing process and by the only when and as a to that objectives are the high a of by the This of described by the as a or to their own their own for described for the process, both and are and to of the The of is that the learner that their are as are their and their the the teacher to the and have for of in would be the of to and and of The of is to further from the of may be when the or to the experience at a but are capable of of used in would or in a of to a of and the of would be one to on or a for from all of may be where little or only In such the the or the through the debriefing many and the of the In little and to only the may to be to a or of of used in would for and and such as active and on and such as and are It is most to facilitate at the with the a of all In experience in this is with or with simulation of any the of to the of the and the is there may be a for to at a more the might to that become at the a is and with this of learning may a of and with a for high but become more as the of as different of may be to the needs of different may be used to in the debriefing process. of other styles of where the or the but from the experience in a manner that its and and or an experience to changes the of from and debriefing is to the feel or such as may also be This which or the for and the the the all the they would or improve on in where the contains examples of or can to the which may out or behaviors. on the or that to be on the and or on the and subsequently this was the Facilitators at the in a to are identified to the simulation in the and subsequently the can be identified and by and by This offers a for debriefing that may facilitate debriefing by Facilitators may to different communication styles or They may also to and or be and there are a of they may to to and within a A of may offer where specific educational or to be expert may on and offer to the particularly where dealing with an experienced of a of facilitators are their to described debriefing to in This is particularly pertinent if the is to such as active and to The The in which debriefing is is also an important more a few often in a from the active of the simulation to of and to a to reflection also the simulation to be set for the not all are the but in for where the aim is to teach a or if the are debriefing may the debriefing. The debriefing be and a a would not be The may vary with the of the debriefing and the of In a more teaching the may at the of the in a more debrief, the may be the from the out of or even the debriefing a is to be may be into might have an or they might and come to their in a describes a of debriefing a the a within a and may to the when they to actively in the that individuals to other to for in as one is from the as a of the type of models and communication styles used and the debriefing is out it is important to be of the in the or many learning experiences debriefing is a of feedback process. the core objectives are for teach a such as or the and reflection on the to We that the learning and of simulation will drive whether a debriefing is and if so how the debriefing process needs to that may from debriefing are training, and this concept of the of the by a sense of and can we through a of the debriefing to the experience. The of the experience in other that that debriefing is what exist the of a of debriefing in Simulation to what experienced felt important elements of a debrief, and also what was felt to a or The was out in to interest in the at a in debriefing at an simulation education that debriefing was the most important of training, to the learning and if the The felt that a was and the of and a of a included the of the of cognitive and of felt where or be of a included the of or on or on the and not on This of experienced facilitators debriefing. many feel that such core elements of debriefing are but if to the of the and the methods of one even debriefing a process for the effectiveness of the debriefing process, which may as a for future the learning objectives or through the was the debriefing time, and the used to the learning objectives given the if at was the debriefing in if of the debriefing process can be about specific and of debriefing. are also more about all of a debrief, and if what have or debriefing or is a if at of simulation the debriefing specific methods of debriefing have specific or are they all A of have the debriefing process In a aiming at dynamic making and simulation-based learning the of the The in a a dynamic such as the role of in an of over and of over four and cognitive The a debrief, the all four the in a medical simulation that to improve if they not As it to on and of complete with of professional and there will be no for an by their We to the of expert there has an interest in In fact, in a of with both A recent healthcare at the ability of to their own and that of their and how that was to of their own and the of their in a of simulation an the formal In the the their in the they over time, the to that of expert This a role for structured and peer it is not whether learned from their that they would not have from the formal facilitated debriefing process. and are often and of expert may be A recent the of medical that achieving and their or to be at and their and but are their the in This is not to but all of experience. A recent review of a ability to to but also and peer debriefing may be to or to A by the of by in a simulation to in their ability to on their A is an that and activities learners and may also for the of a medical and the was into a and those that In this the and collaborative of and learning and and analyzed for both of the learning process. learners more the and felt more active in the debriefing process. may make learning more active and and may to to the debriefing process. whether based simulation with a subsequent in a and it in the for simulation to learning The however, not whether the or the practice on the based was for the in the on the role of the debrief, over a teaching to a their educational experiences to 12 in a attending one of simulation to a on the experience which was to 2 to This reflection on learning over from the or of debriefing. It is also in a of the not feedback as such, may also play a role in this and it to be a fashion. team-oriented in whether for disciplines or for as an in In a the role of in a and the given feedback and their to In the and feedback and within and was for the of the The of is not seen A by debriefing with or in their of debriefing more those but there was no whether the used or This was to the in the In fact, in there was a towards in an debriefing an debriefing with This may have related to a for the or the of the may be for to a to to how they how they they and to in of the the of is currently an not a or are it may of the and may from the of the debriefing often to and doing In a by simulation to in cognitive about the that they would have it was not in this the a debrief, but also a and as of their learning experience. It that the of and of may be as simulation experiences over and are to more out of debriefing of other simulation and their may also play a role in teaching both and A of may be a of not only on teaching but also in debriefing of on the is described as in its with the seen as expert or is this the best to that learning objectives are like an of learning or they it to be more methods to the in and few learners will to a of debriefing, they may that that analysis or result in a to learn at It was with this in that and developed the concept of debriefing with which on a for the adult learner to learn important and into new information with their may feel that this to knowledge in a structured but having to the of their experience and what they learn into their own practice. In a more to a cognitive one. In a to a debriefing (ie, one medical or a cognitive debriefing (ie, the concept of or other models of cognitive the debriefing was by This may be in to the that this type of debriefing is more to the more to the teaching process, where the teacher is the expert and imparts their knowledge in a more linear The of this a combination of approaches may be in practice. They for the debriefing process at whether the debriefing they set out to like the are with what they and what they they when facilitators can their debriefing and how the debriefing how they it A that in that most facilitators more any of the a of to one per the of the debriefing centered on the and to their to or to The of the was only not for the of to and They have also a for and the debriefing process, and the by and their of participation the debriefing This for and to the The the debriefing process. and for are a such as The and the on their as as a is a a of of that this can be used as a means to the of addressed to The is into a and the of by can be as can the of on debriefing may also be by other in the area, such as or to on or practice. of debriefing is for both on a and by attending and from the to the The of and apply not only to but also to operational has and as a of information and The approaches are to healthcare In simulation in or the debriefing of such as in the by illustrate the effectiveness of debriefing in of that teach to their are of this in their simulation for one which debriefing a a medical the of the and to complete a on their experience. felt more to a immediately the simulation and this was even This also that may the practice is not as as may This is in a by the practice of debriefing for by a was by most to be their for debriefing as by and not feel by their a felt more by their This that to have facilitated be not training exercises. This would the lessons learned in simulation and have the best of and between and on This review of the gaps that exist in of the role of debriefing in simulation based learning: such as whether debriefing is required if it what are the most effective to a learning or debriefing in from debriefing, or debriefing novices from debriefing more experienced we the of debriefing and the of such as in the learning process as a A of research would be the of models and of debriefing within the field of simulation-based learning. and of debriefing models both and would be to with other educational methods and collaborative within the simulation community both medical and may an to of the pertinent in simulation-based learning. It is that debriefing is the and of the simulation there is an increasing of the role and effectiveness of debriefing in an manner in the learning process. only a of this has but the presentations of and of the process at on simulation in healthcare are