People learn from experience. If this is always true, why do we all know some people who pass through experiences seemingly without learning a thing? Learning, professional development, and personal improvement don’t come from just having an experience.
During an experience, people are mostly reacting, trying to manage and get through it. Real learning occurs after the experience, on reflection, thinking about the experience in an effective way. This is true whether the experience is “real life” or simulated, in a teaching environment, or on the job.1
Debriefing
One method for effective reflection is debriefing.2 This article presents a simple framework for debriefing that you can use as an educator, clinician, leader, or in your personal life.
Even if you have experienced debriefing before, either as subject or facilitator, these simplified tools should make it easier for you to have more effective debriefing conversations more frequently.
Debriefing is a structured and facilitated, student-centered, post-event learning experience. Although it may sound complex on first read-through, this definition lays out the four critical components of good debriefing.
- It is structured and facilitated, meaning it follows a set format to learn from the experience rather than merely thinking or talking about the experience.
- It is student-centered. Even if the subject of the debriefing is not technically a student, the point is that the focus is for that person to build new knowledge from the experience rather than to receive knowledge, such as tips and tricks from the facilitator, commenting on the experience.
- “Post-event” means the debriefing happens once the experience is done, but not so far after the event that it is difficult for the subject to remember what happened and how they felt about it.3
- Finally, debriefing is where the learning happens. Without effective debriefing, some may learn from an experience, but unfortunately, many people go on emergency calls, participate in classes, or otherwise have experiences they don’t understand, don’t appreciate, or don’t think about long enough to learn. Worst of all, without effective debriefing, they may take away the wrong lessons completely.
Not Overly Formal
Many of us think of debriefing as an overly formal experience that follows a high-fidelity simulation.4 While debriefing can be used in high-fidelity sim labs, it can also be used with tabletop scenarios, clinical lab experiences, hands-on, practical labs, or other classroom or real-world events.
To understand the benefits of using debriefing today, we should first look at how things were taught in the past. When John Amos Comenius was teaching Latin in the 1600s, the primary teaching tool was forcing students to memorize words and phrases, using an actual stick for extra “encouragement” for anyone thought to be “slacking off.”
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The focus was entirely on transferring information from teacher to student rather than helping the student to acquire and apply knowledge. Comenius disliked the idea that “telling was teaching” and redesigned the curriculum so students could learn more from the experience of learning and of using their new language by interacting with each other.5
While he never used the term debriefing, Comenius encouraged students to learn from each other’s successes and mistakes, while other teachers simply told the students when they were wrong and forced them to do it again.
Experience and Education
Fast forward to America in 1938, where John Dewey published “Experience and Education,” a short book still worth reading by any educator today. Dewey was frustrated by the lack of progress in educational methods in the 400 years since Comenius.6
He emphasized the importance of experience and experimentation, emphasizing that mistakes sometimes hold the best learning opportunities.7 Dewey said that learners are not simply blank slates to be filled with knowledge but rather human beings with prior experiences they can use to connect to new learning. Dewey said that the educator’s job is to help students make and strengthen positive learning connections through experiences.
Many consider this to be the beginning of experiential education theory, but Dewey was followed by educators like Malcolm Knowles, who emphasized that adult learners are internally motivated and have their own prior experiences.8,9
Adults want their learning to be self-directed, practical, and relevant.8,9 Educator David Kolb proposed that one of the best ways to accomplish this was by presenting students with concrete experiences, helping them extract new ideas and information by reflecting on those experiences so they could do better the next time around.10
The Four Rs
A framework to put these ideas to work for you is the “four Rs” of experiential learning. These are “React, Reflect, Rules and Repeat.” To use debriefing to help yourself or others learn from an experience, write these down on a piece of paper to help prompt you to consider each part.
React is what happens during the experience. The word “React” reminds us to focus less on the specifics of the event and more on how the student or subject reacted. What did they notice? How did they feel? What did they do?
Reflect is where a debriefing tool is used to help the students focus on learning from how they and others reacted.
Many different debriefing tools can be used, with recommendations later in this article. These all focus on using the experience and reactions for learning and growth, avoiding distractions like blame and fear.
Rules is the step where the facilitator ensures the subjects leave the debriefing ready to use critical take-home points. Students and sometimes educators often overemphasize minor points like tips and tricks.
The rules step is less about establishing rules that must never be broken. It is more about emphasizing the critical points to be used next time.
This leads to the Repeat step, reminding us there will always be a next time. During the repeat step, help the students/subjects explain how they can use their rules in new experiences.
How can they use what they’ve learned on a similar emergency call? How could they use what they’ve learned on a different kind of call?
The framework of the four Rs can help you maximize your use of experiential learning. To support this even more, many debriefing tools can be used for the Reflect step.
The Plus-Delta Model
Different organizations often recommend different debriefing tools with names like the “3-D” model of diffusing, discovering, and deepening, the “GAS” model of gather, analyze and summarize, the “diamond-debrief” of description, analysis, and application, and so on.11 One of the most straightforward is something called the modified Plus Delta technique.12
Plus Delta gets its name from how the facilitator should focus the discussion. The Plus step reminds the educator to help students focus on the positives of how they responded. This does not mean you should tell them they did well when they did not.
It means you should keep your eyes on the prize of education when students/subjects naturally tend to over-emphasize the negatives of their experience. They will often expect you to do the same, waiting for you to tell them who did what wrong. If allowed to happen, this can begin a spiral of negativity. Participants start focusing on failure and blame for themselves, for others, and often for the educators.
Even if the experience itself was stressful with a poor outcome, the point of debriefing is still to have a positive learning experience. The primary focus should be drawing out what went well, especially things that we want to be repeated by the students/subject experiences.
This is followed by Delta, the medical symbol for change. Once the educator has brought out what went well, the focus shifts to what might be changed to improve things. The facilitator can ask questions like, “What would you like to see go differently next time,” or “What can we change to improve the chances for a better outcome?”
Using Plus Delta, you can avoid the pitfalls of blame and focus on how everyone can implement what they’ve learned.
To improve this tool, the modified Plus Delta technique adds an introduction and closure to Plus Delta. The introduction begins by asking how the subject feels about the experience. This may sound too emotional for some educators, but there is an important reason for it.
Using What We Learned
Suppose the students or subjects just had a significant experience, for example, a traumatic cardiac arrest, a challenging patient with difficulty breathing, a stressful, hands-on scenario, etc. In that case, they’ll likely have strong feelings about it.
If we don’t help diffuse those feelings by getting them out in the open, no learning will occur, and the debriefing is pointless. This is especially true when students, for whatever reason, feel their experience was unfair. This “feelings” step also reminds students and teachers that we are all human, and no one can go into a challenging scenario and be expected to respond like a robot.
Learning how to identify, express, and manage one’s feelings is integral to any level of emergency healthcare and should be part of any learning experience.13
The feelings introduction is followed by the Plus focus on the positive things to build on and then the Delta things that can be changed for next time. These are closed out with an explicit statement of the key takeaways.
Discussion
In any discussion about any experience, individuals have their own takeaways, but these might not be the best takeaways to use. It’s up to the educator/facilitator to identify the most important Plus/Delta takeaways for students/subjects to use, whether their next opportunity is in three hours, three months, or three years.
This is how to use debriefing as a structured and facilitated, student-centered, post-event learning experience.14
A “React, Reflect, Rules, and Repeat” framework can help you use any significant real-life or classroom experience as a learning opportunity.
The modified Plus Delta technique can help students diffuse strong emotions, identify positives to build on, identify things to change and take away the right lessons to use for continuing performance improvement.
References
1. Krogh, K., Bearman, M. & Nestel, D. “Thinking on your feet”—a qualitative study of debriefing practice. Adv. Simul. 1, 12 (2016).
2. Tavares, W. et al. Learning Conversations: An Analysis of the Theoretical Roots and Their Manifestations of Feedback and Debriefing in Medical Education. Acad. Med. 95, 1020–1025 (2020).
3. Schrober, P. Effects of post-scenario debriefing versus stop-and-go debriefing in medical simulation training on skill acquisition and learning experience: a randomized controlled trial. (2019).
4. Grant, V. J., Robinson, T., Catena, H., Eppich, W. & Cheng, A. Difficult debriefing situations: A toolbox for simulation educators. Med. Teach. 40, 703–712 (2018).
5. Piaget, J. Jan Amos Comenius. Prospects 23, 173–196 (1993).
6. Manouchehr, P. A CRITICAL COMPARISON OF THE EDUCATIONAL THEORIES AND PRACTICES OF JOHN AMOS COMENIUS WITH JOHN DEWEY’S CONCEPT OF EXPERIENCE. (University of Kansas, 1963).
7. Dewey, J. Experience And Education. (Free Press, 1997).
8. Knowles, M. S. The modern practice of adult education;: Andragogy versus pedagogy,. (Association Press, 1970).
9. Knowles, M. S., III, E. F. H., Swanson, R. A., SWANSON, R. & Robinson, P. A. The Adult Learner. (Routledge, 2020).
10. Kolb, A. Y. & Kolb, D. A. Learning Styles and Learning Spaces: Enhancing Experiential Learning in Higher Education. Acad. Manag. Learn. Educ. 4, 193–212 (2005).
11. Sawyer, T., Eppich, W., Brett-Fleegler, M., Grant, V. & Cheng, A. More Than One Way to Debrief: A Critical Review of Healthcare Simulation Debriefing Methods. Simul. Healthc. J. Soc. Simul. Healthc. 11, 209–217 (2016).
12. Cheng, A. et al. Embracing informed learner self-assessment during debriefing: the art of plus-delta. Adv. Simul. 6, 22 (2021).
13. Szyld, D. & Rudolph, J. W. Debriefing with Good Judgment. in The Comprehensive Textbook of Healthcare Simulation (eds. Levine, A. I., DeMaria, S., Schwartz, A. D. & Sim, A. J.) 85–93 (Springer New York, 2013). doi:10.1007/978-1-4614-5993-4_7.
14. Eppich, W. J., Hunt, E. A., Duval-Arnould, J. M., Siddall, V. J. & Cheng, A. Structuring feedback and debriefing to achieve mastery learning goals. Acad. Med. J. Assoc. Am. Med. Coll. 90, 1501–1508 (2015).
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