Shimaoka debriefing

Debriefing When Learning Occurs

ふりかえり

あいかわらず依然として得体の知れないもの

Debriefing

Review Articles

The Role of Debriefing in Simulation-Based Learning

Ruth M. Fanning, Mb, MRCPI,FFARCSI;

and David M. Gaba, MD

The aim of this paper is to critically review what is felt to beimportant about the role of debriefing in the field of simula-tion-based learning, how it has come about and developedover time, and the different styles or approaches that are usedand how effective the process is. A recent systematic review ofhigh fidelity simulation literature identified feedback (in-cluding debriefing) as the most important feature of simula-tion-based medical education.1 Despite this, there are sur-prisingly few papers in the peer-reviewed literature toillustrate how to debrief, how to teach or learn to debrief,what methods of debriefing exist and how effective they are atachieving learning objectives and goals.

This review is by no means a systematic review of all theliterature available on debriefing, and contains informationfrom both peer and nonpeer reviewed sources such as meet-ing abstracts and presentations from within the medical fieldand other disciplines versed in the practice of debriefing suchas military, psychology, and business. It also contains manyexamples of what expert facilitators have learned over years ofpractice in the area. We feel this would be of interest to nov-ices in the field as an introduction to debriefing, and to ex-perts to illustrate the gaps that currently exist, which might beaddressed in further research within the medical simulationcommunity and in collaborative ventures between other dis-ciplines experienced in the art of debriefing.

THE BACKGROUND OF SIMULATION-BASEDLEARNING

Generally, in simulation-based learning, we are dealingwith educating the adult professional. Adult learning pro-vides many challenges not seen in the typical student popu-lation. Adults arrive complete with a set of previous life ex-periences and frames (“knowledge assumptions, feelings”),ingrained personality traits, and relationship patterns, whichdrive their actions.2 Adult learners become more self-di-rected as they mature. They like their learning to be problemcentered 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 willvary and depend on factors such as their motivation for at-tending training, on whether it is voluntary or mandatory,and whether participation is linked directly to recertificationor job retention. Traditional teaching methods based on lin-ear communication models (ie, a teacher imparts facts to thestudent in a unidirectional manner) are not particularly ef-fective in adult learning, and may be even less so in team-oriented training exercises. The estimated half-life of profes-sional knowledge gained through such formal education maybe as little as 2 to 2.5 years.4 In the case of activities requiringboth formal knowledge and a core set of skills, such as Ad-vanced Cardiac Life Support, retention can be as little as 6 to12 months.5,6

Much of the research in teaching adults indicates thatactive “participation” is an important factor in increasing theeffectiveness of learning in this population.7 In fact, in anygiven curriculum, learning occurs not only by the formalcurriculum per se but informally through personalizedteaching methods (informal curricula), and even more sothrough embedded cultures and structures within the orga-nization (hidden curricula).8

Adults learn best when they are actively engaged in theprocess, participate, play a role, and experience not only con-crete events in a cognitive fashion, but also transactionalevents in an emotional fashion. The learner must make senseof the events experienced in terms of their own world. Thecombination of actively experiencing something, particularlyif it is accompanied by intense emotions, may result in long-lasting learning. This type of learning is best described asexperiential learning: learning by doing, thinking about, andassimilation of lessons learned into everyday behaviors. Kolbdescribes the experiential learning cycle as containing fourrelated parts: concrete experience, reflective observation, ab-stract conceptualization, and active experimentation.9 Gibbsalso describes four phases: planning for action, carrying outaction, reflection on action, and relating what happens backto theory.10 Grant and Marsden similarly describe the expe-riential learning process as having an experience, thinkingabout the experience, identifying learning needs that wouldimprove future practice in the area, planning what learning toundertake, and applying the new learning in practice.11

Simulation training sessions, which are structured withspecific learning objectives in mind, offer the opportunity to

From the Department of Anesthesia, Stanford University, Stanford, CA.

The authors have indicated they have no conflict of interest to disclose.Reprints: Ruth M. Fanning, Department of Anesthesia, StanfordUniversity Medical School, 300 Pasteur Drive, Stanford, CA 90314 (e-mail:[email protected]).

Copyright © 2007 Society for Simulation in HealthcareDOI: 10.1097/SIH.0b013e3180315539

Vol. 2, No. 2, Summer 2007 115

Society for Simula9on in Healthcare 2007

Debriefingに関する総説

私たちの学びにおいてもっとも大きな要素はなにか

経験学習学習とは経験の変換によって知識が形成される過程である

Kolb

Experience

Simulation

安全な状況下で

を提供する

体験することが目的ではない

体験して学び取ることが目的

経験学習学習とは経験の変換によって知識が形成される過程である

Kolb

Not everyone is naturally capable of analyzing, making sense, and assimila9ng learning experience on their own, par9cularly those included in Highly dynamic team based ac9vi9es.

すべての人が自らの学習経験を分析したり意味付けしたりすることができるわけではない

Debriefing represents facilitated or guided reflec9on in the cycle of experien9al learning

デブリーフィングとは経験学習サイクルの中でファシリテーション、もしくはガイドつきで行われる「振り返り」である　　　　　　

そこでデブリーフィングが登場する….

THE DEBRIEFING PROCESS

Models of Debriefing

The natural order of human processing （普通のプロセスとして） 1) to experience an event（ある出来事を経験する） 2) to reflect on it（それを振り返る（内省する）） 3) to discuss it with others（他者と話し合う） 4) learn and modify behaviors based on the experience 　　　　（学習し、その経験に基づき行動変容をする。）

Reflec9on aYer learning experience might occur naturally, but it is likely to be unsystema9c.

システマチックに行える方法として、、、デブリーフィングが必要

普通にしていれば学習経験のあとの振り返りは自然と生じるはずだがでも、それはあまりシステマチックにはならないんですね、、、

Debriefing Process Ini9al phase : The recollec9on of what happened and discrip9on of what par9cipant did in their own words 　　　　　　　　(自分の言葉で何がおこったのか、何をしたのか説明） Second Phase : Described as iden9fying the ways in which emo9on 　　　　　　　　　　was involved　either individually or for the group 　　　　　　　（どのように思ってどのように感じてそのようにしたかを説明） Third Phase : iden9fying the different views formed by each 　　　　　　　　par9cipant and　how they correlate with the picture as 　　　　　　　　a whole; generaliza9on and applica9on of the 　　　　　　　　experience, during which par9cipants a^empt to make comparisons with real life events 　　　　　　　　　　　　　　（客観的に参加者それぞれの視点から考える。　　　　　　　　　　　　　実際の出来事と比較してみて一般化していく。）

「ふりかえりの 3ステップ」何を(what?)、だから何/なぜ(so what?)、ゆえに何/どうする(now what?) という構造化を用いる


To Debrief or Not?（デブリーフィングをするのかしないのか）

Typically topics that at benefit from debriefing(デブリーフィングが効果的なのは？） 1) Team training（チームワークトレーニング） 2) Crew resource management（CRMスキルトレーニング） 3) Mul9disciplinary training（多職種トレーニング）

Teaching technical skills,such as intunba9on, does not require In-‐depth debriefing or reflec9ons

Learning objec9ves, Target popula9on, and modali9es of simula9on will drive whether a debriefing is useful or not

テクニカルスキルにおいてはあまり深いデブリーフィングは要求されない

学習目標、どのようなグループに行うか、シミュレーションの種類などによってデブリーフィングが有効かそうでないかが分かれる

もしできなかったら

失敗したらどうしよう


Approach to Debriefing（デブリーフィングに際し考慮すべきこと）

Approximately half of the par9cipants found It a stressful and in9mida9ng environment fear of the educator and their peer’s judgement

参加者の約半数が　　教える側の人間や一緒に受講する人による　　　　　「自分に対する評価」をストレスに感じている



Facilitator must provide a ‘suppor9ve climate’ where students feel valued, respected, And free to learn in a dignified environment.

ファシリテーターは受講者が尊重され、自由に学べるような「支持的環境（SUPPORTIVE CLIMATE）」を作らなくてはならない



Par9cipants need to be able to ‘share their experiences in a frank, open, and honest manner’

受講者側もフランクに、オープンに、正直に経験を共有することができるように


Role of the Facilitator in the Debriefing Process

the skill of facilitators as being an important factor in the learning process and the CREDIBILITY OF THE COURSE

ファシリテーターのスキル　　　→学習のプロセスにおいての重要な要素　　　　コースの信頼度にも関わってくる


Role of the Facilitator in the Debriefing Process

UNLIKE THE TRADITIONAL CLASSROOM TEACHER, facilitators tend to posi9on themselves not as authori9es or Experts, but rather as COLEARNERS

伝統的な教師と異なり、ファシリテーターは「ともに学ぶ人」という立場

THE LEVEL OF FACILITATION and THE INVOLVEMENT IN THE DEBRIEFING PROCESS　 DEPEND ON A VARIETY OF GENERIC FACTORS 　　　　　　　　　　（いろいろな要素でファシリテーションの度合いはかわるのです） 1　 The objec9ve of the experien9al exercise（目的） 2　 the complexity of the scenarios（シナリオの複雑さ） 3 　the experience level of the par9cipants as individuals or team（経験の差） 4　 The familiality of the par9cipants with the simula9on environment（慣れ） 5 　9me available for session（時間） 6 　The role of simula9on in the overroll curriculum（シミュレーションの役割） 7 　Indivisual personali9es and rela9onships, if any, between par9cipants（個人の関係性）

Three Levels of facilita9on in Debriefing Process

Par9cipants largely debrief themselves 　　　　　　　　（自分でdebriefingできるチームの場合） Facilitators gently guide the discussion only when necessary 　　　　　　　　（必要なときだけ介入） High level faci. Is a low level of involvement 　　　　　　　　（ファシリテーション高い、介入度低い） Fasilitator as catalyst 　　　　　　　（ファシリテーターは触媒） The use of pauses to allow thoughmul responses and comment （ちょいと待つ） Open-‐ended ques9on, and phrases rather than statements of fact （決めつけるよりはオープンクエスチョン） The armul use of silence is the technic to draw further discussion from the group （沈黙をより深いディスカッションのために使用する）

High


Increased level of instructor involvement 　　　　　　　　　　　　（より介入の度合いがあがる） Individuals and teams requires help to analyze in deep levels 　　　　　　　　　　　　　　　　　but are capable of much independent discussion 　　　　　　　　　　　　（助けはいるがちょいと助けると勝手に進んで行く） Rewording and Rephrasing rather than giving an answers 　　　　　　　　　　　　（答えを与えるより言い方を変えて話してみる）

intermediate

An intensive level of instructor involvement.（かなり集中的にインストが介入） Teams show li^le ini9a9ve or respond only superficially（表面的な反応でしかない） Asking many Ques9ons / strongly directs the nature of discussion（たくさん質問する） Faciitators needs to be direc9ve to operate a stepwise or pa^ern of analysis 　　　　　　　　　　　　　　　　　　　　　　　　　　　　（かなり指導的に細かく分析が必要） Ex) answering for par9cipants（答える） / confirming statements（確認する）　　 agreeing（承認する） /reinforcing thoughts and ideas（考えを強化する）　　 ac9ve listening（能動的にきく） / 　　　nonverbal encouragement such as nodding, leaning forward, and focused eye contact（非言語的な承認勇気づけ）

Low



The Debriefing Seong

Debriefing oYen take place in a room separate from the ac9ve por9on of the Simula9on to allow diffusion of ten9on and to provide a seong conduc9ve to Reflec9on (場所を変える　テンションの開放など）

The debriefing room should be comfortable private, and a rela9vely in9mate emvironment(ex a large auditorium would typically not to be appropriate) 　　　　　　　　　　（居心地のよい場所　あまり広すぎない場所）



The sea9ng arrangement may vary with the style of debriefing 　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　 and the degree of facilita9on intended 　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　 Tradi9onal teaching aproach : the facilitator may posi9on himself at the head of the table 　　　　　　　　　　　　　　　　（伝統的な教え方ではテーブルのトップに偉い人が座る） Per9cipant-‐directed debrief : the facilitator may posi9on himself among the par9cipants away from the table / out of the sight / outside of the room 　　　　　　　　　　　　　　　　　（部屋から出て行っていい！！）



Not all debriefings are held aYer the sims : 　　 teaching technical skils team behaviors are seriously flawed 　　　　　　　　　　　　　　　　　　　‘ in scenario debriefing ’

（デブリーフィングは必ずしもシナリオの終わりにやらなくてもよい）

THE DEBRIEFING PROCESS The Effec9veness of Debriefing Sessions

Elements of a good debrief　 The use of open-‐ended ques9on 　　　　　　（オープンクエスチョン）Posi9ve reinforcement 　　　　　　（前向きな強化） The use of cogni9ve aids 　　　　　　（認知的補助） The good use of audiovisual 　　　　　　　　　　　　　　　capabili9es 　　　　　　（視聴覚機材の使用）

Elements of a poor debrief The use of closed ques9ons 　　　　　　　　（クローズドクエスチョン） Cri9cism（批判的） Ridicule（侮辱的） Concentra9ng on errors（エラーにだけ） Concentra9ng too much on technical points 　　　　（テクニカルなことにだけ） Not enough on CRM skills 　　　　（CRMスキルについて十分出ない）

Performed poorly could harm the trainee Crea9ng a non-‐threatnening　atmosphere

Shimaoka debriefing

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