The Role of Debriefing in Simulation-Based Learning

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. 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