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. This military-style debriefing was both educational and operational in its objectives. Another connotation of debriefing developed out of the combat arena as a therapeutic or psychological association, as sort of “defusing,” and aided the processing of a traumatic event with the aim of reducing psychologic damage and returning combatants to the frontline as quickly as possible. In this therapeutic approach, emphasis was placed on the importance of the narrative to reconstruct what happened. This cognitive reconstruction of events was performed in groups so that there was a shared meaning. The participants were brought together to describe what had occurred, to account for the actions that had taken place, and to develop new strategies with each other and the commanding officers. Another form of debriefing, critical incident debriefing, was pioneered by Mitchell15 and is used to mitigate stress among emergency first responders. He formulated a set of procedures termed the Critical Incident Stress Debriefing (CISD).15 CISD is a facilitator-led approach to enable participants to review the facts, thoughts, impressions, and reactions after a critical incident. Its main aim is to reduce stress and accelerate normal recovery after a traumatic event by stimulating group cohesion and empathy. Dyregrov modified this technique and called it psychological debriefing, designed to take place in the 48 to 72 hours after a traumatizing event in an attempt to assist participants in the cognitive and emotional processing of what they experienced.16 Currently, there is concern that an unrealistic expectation of CISD and its usefulness may be developing. A single session approach may be inadequate for certain individuals and situations, particularly as the technique is applied outside the realms for which it was originally designed.17 Another origin for the term “debriefing” comes from experimental psychology, and describes the means by which participants who have been deceived in some manner as part of a psychology study are informed of the true nature of the experiment.18 The purpose of this ethically required debrief is to allow dehoaxing to occur, and to reverse any negative effects the experience may have had.19 Each of the three fields have contributed to the development of debriefing in the educational arena, facilitator-led participant discussion of events, reflection, and assimilation of activities into their cognitions produce long-lasting learning. THE DEBRIEFING PROCESS Approach to Debriefing Just as in noneducational debriefing, where there exists an ethical duty of facilitators to set a safe, confidential scene for facilitation, there is the ethical obligation for the facilitator in simulation-based learning to determine the parameters within which behavior will be analyzed, thereby attempting to protect participants from experiences that might seriously damage their sense of self-worth.20 To ensure a successful debriefing process and learning experience, the facilitator must provide a “supportive climate”21 where students feel valued, respected, and free to learn in a dignified environment. Participants need to be able to “share their experiences in a frank, open and honest manner.”14 An awareness of the vulnerability of the participant is needed, which must be respected at all times. This is highlighted by a recent study regarding the barriers to simulation-based learning, where approximately half the participants found it a stressful and intimidating environment and a similar proportion cited a fear of the educator and their peers' judgment.22 It is essential that the facilitator creates an environment of trust early on, typically in the prebrief session. This prebrief period is a time when the facilitator illustrates the purpose of the simulation, the learning objectives, the process of debriefing, and what it entails. It is the period where the participants learn what is expected of them and sets the ground rules for their simulation-based learning experience. It is also a time for the facilitator to reflect on the learning objectives, and to consider that every participant comes to the simulation with a preceding set of individual frames and life experiences.2 These previous experiences have an impact on how effective training will be, and need to be taken into consideration irrespective of the debriefing model employed. These frames or internal images of reality, how a person perceives something relative to someone else, affect the way people receive, process, and assimilate information.2 The simulation scenario and the debriefing techniques employed need to take individual learning styles into consideration. This factor is illustrated by Kolb with the incorporation of the experiential learning cycle with basic learning styles.23 Four prevalent learning styles are identified: diverging, assimilating, converging, and accommodating. Participants with diverging learning styles use concrete experience and reflective observation to learn. This style facilitates generation of ideas, such as brainstorming. Individuals with this learning style prefer to work in groups, listening and receiving feedback. Individuals with assimilating learning styles prefer abstract conceptualization and reflective observation. They like reading, lectures, and analysis. Converging-styled learners use abstract conceptualization and active experimentation. They like to find practical uses for ideas and theories. In a formal learning setting, they prefer to experiment with new ideas, simulations, laboratory experiments, and practical applications. Accommodating-styled learners use concrete experience and active experimentation. People with this style learn primarily from hands-on experience. In formal learning, they prefer to work in teams, to set goals, to do fieldwork, and to test different approaches to compiling a project. When learning in teams, individuals tend to orientate themselves and contribute to the team learning process by using their individual learning styles to help the team achieve its learning objectives. Highly effective teams tend to possess individuals with a number of different learning styles. In our experience, pairing appropriately learning-styled individuals may add to the team's performance. Individual learning styles and team composition are important factors for facilitators to consider when choosing which style of debriefing will be most successful for each simulation session. It is also important for facilitators to learn about the characteristics of the group: whether group members know each other, are novices or are experienced, or are new to simulation. The prebrief period can afford the experienced facilitator an opportunity to observe team behaviors and identify learner characteristics early on, and debrief accordingly. Structural Elements of the Debriefing Process Despite many approaches to debriefing,24,25 there are a number of structural elements common to most forms of facilitation. Lederman identified seven common structural elements involved in the debriefing process (Table 1).18 The first two elements are the debriefer(s) and those to be debriefed. It is possible for these two to be the same if participants act as their own debriefers.26 The third element is the experience itself (eg, the simulation), and the fourth is the impact this experience has on the participants. The concept of impact is important because adult learners typically need to be emotionally moved by the event, and the event needs to be relevant to their everyday lives to make an impact. The fifth and sixth elements involve recollection and report. Reporting of the event, although usually carried out in a verbal manner, may be written or involve the completion of a formal questionnaire.24 The seventh element is time: the experience will be seen differently depending on how much time has passed before the debriefing. Although most debriefing approaches are conducted very soon after the experience, some allow more time for formal reflection, with reporting long after the event via a written report of an individual event or through keeping a journal (a written review of educational experiences over a semester).24Table 1: Seven Common Structural Elements Involved in the Debriefing Process18Models of Debriefing A number of models exist incorporating these structural elements and describe various debriefing or facilitation styles.27–29 These models probably all evolve out of the natural order of human processing: to experience an event, to reflect on it, to discuss it with others, and learn and modify behaviors based on the experience. Although reflection after a learning experience might occur naturally, it is likely to be unsystematic. It may not occur at all especially if the pressure of events prevents focusing on what has just transpired. Conducting a formal debriefing focuses the reflective process, both for individual participants and for the group as a whole. Naturally, debriefings may move of their own power through three phases: description, analogy/analysis, and application. However, without a facilitator participants may have trouble moving out of this first descriptive phase, particularly the active “hot-seat” participant who is emotionally absorbed in the event and is blinkered in their view of what has occurred. The challenge for the facilitator is to allow enough time for defusing to occur, but direct the discussion in a more objective, broad-based capacity. The facilitator needs to move the discussion away from the very personalized account of what the participant thought occurred, to the more global perspective, away from the individual to the group, and the person to the event, but must be cognizant not to cut the participant off, or make him/her feel alienated. Although the core of the debrief centers on reflection of the active experience and making sense of the event, there are supporting phases that are necessary to allow this reflection and assimilation to occur. These phases of the debrief are described by many authors, and are categorized in different manners. The basic tenets of the various debriefing models have many overlapping elements (Table 2).Table 2: Models of the Debriefing ProcessAn initial phase of identifying the impact of the experience, considering the processes that developed and clarifying the facts, concepts, and principles which were used in simulation is described by Thatcher and Robinson.27 Lederman describes this phase as the introduction to systematic reflection and analysis that follows the active component of the simulation: “the recollection of what happened and description of what participants did in their own words.”28 Paternek describes this introductory phase as the description of the events that occurred.29 The second phase is described as identifying the ways in which emotion was involved, either individually or for the group;27 the intensification and personalization of the analysis of the experience, where participants explore the feelings they experienced during the event;28 or the emotional and empathic content of the discussion.29 The third phase involves identifying the different views formed by each participant, and how they correlate with the picture as a whole;27 the generalization and application of the experience, during which participants attempt to make comparisons with real-life events;28 a phase of explanations and analysis, everyday applicability and evaluation of behaviors.2 Objectives of the Debriefing Session The design of the debriefing session should be tailored to the learning objectives and the participant and team characteristics. Objectives may be well defined, and specified beforehand, or may be emergent and evolve within the simulation. For well-defined objectives, such as a technical skill or a particular team behavior, the debriefing session affords the opportunity to examine how closely participants' performance has approached a known target, and what needs to be done to bridge any observed gaps between performance and target. It also affords an opportunity to share these objectives with participants. With emergent objectives, participants may be asked to reflect on the observed evolution of the scenario and to see how the behaviors, attitudes, and choices uncovered in the simulation relate to real life situations. When exploring objectives or goals, there are two main questions: 1) which pieces of knowledge, skills, or attitudes are to be learned? and 2) what specifically should be learned about each of them? In the case of emergent objectives, simulations may be viewed as experiments in which participants try alternative ways of behavior or test new strategies or courses of action. To debrief about such objectives is complicated because there are fewer predefined ideas about how the participants should have acted, so discussion must focus around issues that arise from the events themselves and their meaning to those involved. Role of the Facilitator in the Debriefing Process There is a tension between making participants active and responsible for their own learning versus ensuring they address important issues and extract maximum learning during debriefings. Data from surveys of participants indicates that the perceived skills of the debriefer have the highest independent correlation to the perceived overall quality of the simulation experience.30 As the skill of the debriefer is paramount in ensuring the best possible learning experience, training in facilitation is vital. A number of centers offer facilitation courses providing training in debriefing skills (Table 3).31 In addition to the formal education of facilitators, techniques such as the pairing of expert with novice facilitators early in their career to give guidance and direction are important. A recent study of facilitation in problem-based learning illustrated that while facilitators felt that a formal training course provided sufficient skills to commence debriefing, it was only with experience, and in the presence of an expert role model that they became more comfortable with the process.32 In the same study, students commented on the skill of facilitators as being an important factor in the learning process and the credibility of the course. Basic and advanced courses and refresher courses in facilitation are probably universally required.Table 3: List of Institutions and Organizations that Offer Formal Training for the Simulation-based Healthcare Educator31The exact level of facilitation and the degree to which the facilitator is involved in the debriefing process can depend on a variety of generic factors: The objective of the experiential exercise, The complexity of the scenarios, The experience level of the participants as individuals or a team, The familiarity of the participants with the simulation environment, Time available for session, The role of simulations in the overall curriculum, Individual personalities and relationships, if any, between the participants. Unlike the traditional classroom “teacher,” facilitators tend to position themselves not as authorities or experts, but rather as colearners. This more fraternal approach may be most productive where the learning objective is behavioral change. Facilitators aim to guide and direct rather than to lecture. The role of the student or participant in debriefing is expanded from the traditional passive role to one where the skills demanded of them are the ability to critically analyze one's own performance retrospectively—not just what went well but what went wrong, and why it went that way, and to contribute actively to the learning process. Practical Points on Debriefing There are a number of methods of debriefing, and levels of facilitation that may be employed. Dismukes and Smith, while discussing debriefing in aviation, delineate three levels of facilitation.33 High Participants largely debrief themselves with the facilitator outlining the debriefing process and assisting by gently guiding the discussion only when necessary, and acting as a resource to ensure that objectives are met. Thus, paradoxically the high level facilitation actually implies a low level of involvement by the facilitator. This level of facilitation—initially described by Carl Rogers—describes the facilitator as a catalyst, allowing clients or students to draw their own conclusions, creating their own prescription for change.34 He described “core conditions” for the facilitative process, both counseling and educational. These are congruence (realness), acceptance, and empathy. Realness refers to genuine nature of the facilitator. The idea of acceptance is that the learner feels that their opinions are prized, as are their feelings and their person. For the third, empathy, the teacher aims to understand the learner's viewpoint and have sensitivity for it. Examples of techniques in high-level facilitation would be the use of pauses to allow thoughtful responses and comment, open-ended questions and phrases rather than statements of fact. The artful use of silence is another technique to draw further discussion from the group. Intermediate An increased level of instructor involvement may be useful when the individual or team requires help to analyze the experience at a deep level, but are capable of much independent discussion. Examples of techniques used in intermediate-level facilitation would include rewording or rephrasing rather than giving answers, asking questions in a number of ways to a number of participants and changing the tone of questions. Other techniques would be asking one member to comment on another, or moving around a group asking for input from all team members. Low An intensive level of instructor involvement may be necessary where teams show little initiative or respond only superficially. In such cases the facilitator guides the individual or the group through the debriefing stages, asks many questions and strongly directs the nature of the discussion. In low-level facilitation, participants show little initiative and tend to respond only superficially. Here the facilitator may need to be directive to operate a stepwise or pattern of analysis. Examples of techniques used in low-level facilitation would include answering for participants, confirming statements, agreeing, recapping, and reinforcing thoughts and ideas. Other techniques such as active listening, echoing, and expanding on statements and nonverbal encouragement such as nodding, leaning forward, and focused eye contact are useful. It is probably most beneficial to facilitate at the highest possible level, with the participants independently generating a rich discussion among themselves of all key issues. In our experience in healthcare, this ideal is rarely achieved, especially with relatively junior trainees or with first-time simulation participants of any age. Matching the level of instructor involvement to the nature of the material and the group is critical. Conversely, there may be a tendency for instructors to debrief at a lower level (with more instructor involvement) than the participant group might really need—that is, to “overinstruct.” To ensure that participants become involved at the highest level, a good prebrief is essential. Individuals and teams unfamiliar with this kind of learning may start off a sequence of simulations and debriefings with a need for high instructor input but then become more participant-directed as the day progresses. Other Styles of Facilitation Just as different levels of facilitation may be employed to suit the needs of participants, different facilitator techniques may be used to engage participants in the debriefing process. Examples of other styles of facilitation include: funneling, where the facilitator guides or funnels the participants, but refrains from commenting; framing, introducing the experience in a manner that enhances its relevance and meaning; and frontloading, using punctuated questions before or during an experience to redirect reflection. Solution-focused facilitation changes the focus of questions away from problems, and directional-style debriefing is intended to change the way people feel or think.35 Techniques such as plus-delta may also be useful. This technique which involves creating two headings or columns entitled delta, the Greek symbol for change, and plus. Under the delta column, the participants or/and the facilitator place all the behaviors/actions they would change or improve on in future, where the plus column contains examples of good behaviors or actions. Different participants can contribute to the critique, which may single out individual or team behaviors. Variations on the technique include placing behaviors or actions that were found to be difficult on the delta column, and easier tasks or behaviors on the plus column, and subsequently discussing why this was the case. Facilitators at the Karolinska University Hospital in Sweden use a target-focused technique to aid facilitation.36 Target behaviors are identified prior to the simulation scenario in the prebrief period, and subsequently during the debrief these can be identified and evaluated by facilitators, participants, and by observers. This technique offers a structure for debriefing that may facilitate debriefing by participants. Facilitators may decide to use different communication styles while debriefing: using commands, cues, or questions. They may also decide to use acceptance and praise or be scolding and corrective.37 If there are a number of debriefers, they may decide to use opposing styles: “good cop-bad cop” to encourage discussion and cohesiveness within a participant team. A group of debriefers may offer advantages where specific educational or technical points need to be addressed. An expert (expert content debriefer) may debrief on specialized issues and offer credibility to the discussion, particularly where dealing with an experienced group of participants. When a number of facilitators are present, their roles need to clearly described before debriefing commences to avoid excessive facilitator input in discussions. This is particularly pertinent if the principal debriefer is attempting to use techniques such as active listening and silence to encourage group participation. The Debriefing Setting The physical environment in which debriefing is conducted is also an important factor. For complex debriefings lasting more than a few minutes, debriefings often take place in a room separate from the active portion of the simulation to allow diffusion of tension and to provide a setting conducive to reflection (this also frees up the simulation room to be set up for the next scenario). However, not all debriefings are held after the simulation, but in certain instances, for example, where the aim is to teach a technical skill or if the team behaviors are seriously flawed, debriefing may occur during the simulation, “in-scenario” debriefing. The debriefing room should be comfortable, private, and a relatively intimate environment (for example, a large auditorium would typically not be appropriate). The seating arrangement may vary with the style of the debriefing and the degree of facilitation i