IMSH Research Summit

Debriefing Methods for Simulation in Healthcare

A Systematic Review
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Jonathan P. Duff, MD, FRCPC, MEd; Abstract: Debriefing is a critical component in most simulation experiences. With the
growing number of debriefing concepts, approaches, and tools, we need to understand
Kate J. Morse, NP, PhD; how to debrief most effectively because there is little empiric evidence to guide us in their
use. This systematic review explores the current literature on debriefing in healthcare simu-
lation education to understand the evidence behind practice and clarify gaps in the litera-
Julia Seelandt, PhD;
ture. The PICO question for this review was defined as “In healthcare providers [P], does the
use of one debriefing or feedback intervention [I], compared to a different debriefing or
Isabel T. Gross, MD, PhD; feedback intervention [C], improve educational and clinical outcomes [O] in simulation-based
education?” We included 70 studies in our final review and found that our current debriefing
Melis Lydston, MLS; strategies, frameworks, and techniques are not based on robust empirical evidence. Based
on this, we highlight future research needs.
Joan Sargeant, PhD; (Sim Healthcare 19:S112–S121, 2024)

Key Words: Debriefing, simulation, feedback.

Peter Dieckmann, PhD;

Joseph A. Allen, PhD;

Jenny W. Rudolph, PhD;

Michaela Kolbe, PhD, PD

H ealthcare simulation-based training contributes to enhanced

patient care.1–4 Debriefing is a critical component in most sim-
In simulation-based education, debriefing is defined as
guided conversation among participants that aims to explore
ulation experiences and many scholars consider the debriefing and understand the relationships among events, actions, thought
of simulated cases essential for learning.5–11 However, there is and feeling processes, and performance outcomes of the sim-
little empiric evidence to guide its use. Debriefing is an art that ulated situation.21–25 Educational debriefings are associated
is difficult to learn.12–15 With the growing number of debriefing with large, positive effects on clinical performance—in simu-
concepts approaches and tools, we need to understand clearly lation and beyond.19,26–28 For example, the World Health Or-
how to debrief most effectively.16–20 ganization recommends to consider education debriefings “as
part of continuous learning and improvement.”29(p27) How-
ever, if done poorly, formative feedback and debriefings can
have a negative impact on learning.30
From the Department of Pediatrics (J.P.D.), University of Alberta. Edmonton, Canada;
College of Nursing and Health Professions (K.J.M.), Drexel University, Philadelphia, PA; Many clinicians and educators report struggling with lead-
Simulation Centre (J.S., M.K.), University Hospital, Zurich, Switzerland; Department of ing debriefings.12–15 Steinwachs31 provided an early framework
Pediatrics, Section of Emergency Medicine (I.T.G.), Yale University School of Medicine, for debriefing after simulation (in this case a simulation game)
New Haven, CT; Treadwell Virtual Library (M.L.), Massachusetts General Hospital,
Boston, MA; Faculty of Medicine (J.S.), Dalhousie University, Halifax, Canada; with 3 phases identified that occur organically in many debriefings:
Copenhagen Academy for Medical Education and Simulation (CAMES) (P.D.), Herlev, description, analysis/analogy, and application. Over the past
Denmark; Department of Quality and Health Technology (P.D.), University of Stavanger, years, healthcare simulation education scholars have built on
Stavanger, Norway; Department of Public Health (P.D.), University of Copenhagen,
Denmark; Department of Family and Preventive Medicine (J.A.A.), University of Utah, this work and developed a variety of debriefing approaches
Salt Lake City, UT; Center for Medical Simulation (J.W.R.), Boston, MA; and ETH Zurich and tools, for example, “Debriefing with Good Judgment,”10,21
(M.K.), Zurich, Switzerland. “PEARLS,”32 “The Debriefing Diamond,”33 Gather-Analyze-
Correspondence to: Jonathan Duff, MD, FRCPC, MEd, 3-456 Edmonton Clinic Health Summarize,34 Rapid Cycle Deliberate Practice (RCDP),35 and
Academy (ECHA), University of Alberta, 11405 87th Ave, Edmonton, AB, Canada T6G
1C9 (e‐mail: jduff@[Link]). “TeamGAINS.”36 Many of these frameworks focus on creating
P.D. holds a professorship with the University of Stavanger, Norway, that was supported and maintaining ideal debriefing conditions,37–39 managing
by the Laerdal Foundation but is now financed by the University. P.D. is in the leadership challenging debriefing situations,38,40 and the complexity and
of the EuSim group. The other authors declare no conflict of interest. dynamics among team members.11,17,24,41,42 Many different
Supplemental digital content is available for this article. Direct URL citations appear in the variables interact during debriefings leading to a complex event
printed text and are provided in the HTML and PDF versions of this article on the
journal’s Web site ([Link]). that can be difficult to understand well.27
Copyright © 2023 Society for Simulation in Healthcare In the simulation literature, empiric studies of debriefing im-
DOI: 10.1097/SIH.0000000000000765 pact are limited.42–45 Studies comparing the use and effectiveness

S112 Debriefing Methods for Simulation in Healthcare Simulation in Healthcare

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 of different approaches are currently lacking. This is problem- Data Extraction
atic because decades of team science have demonstrated that Five authors (J.P.D., M.K., J.S., K.M., I.T.G.) extracted
the way team members interact and reflect strongly impacts data about study characteristics into a data collection tool, in-
their performance.43,46–49 Evidence-driven knowledge of ef- cluding details about the study design, outcomes, and debriefing
fective processes is often required for meaningful, timely, characteristics (see Table, Supplemental Digital Content 2, data
and effective interventions for improving the quality and extraction tool, [Link] Each study data
safety of patient care.50–52 This systematic review explores were extracted independently by 2 of the 4 researchers involved
the current literature of debriefing in healthcare simulation in data extraction (with each article reviewed by one of the lead
education to understand the evidence behind practice and authors). Disagreements were discussed until agreement was
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clarify gaps in the literature. reached. In case of missing data, we left the respective extrac-
tion field empty.
METHODS Data Terms
This review was reported according to the Preferred Reporting We extracted data on the study characteristics and methods,
Items for Systematic Reviews and Meta-Analysis (PRISMA) characteristics of the simulation being performed, details about
2020 statement.53 Electronic searches for published literature the debriefing including framework used, structure of the de-
were conducted by a medical informationalist (M.L.) using brief, and information about the debriefers themselves. Simu-
Ovid MEDLINE (1946 to present), [Link] (1947 to lations and debriefs were classified as being multiprofessional
present), Web of Science (1900 to present), Cochrane Central (different professions present such as physicians, nurses, respira-
Register of Controlled Trials via Ovid (1991 to present), ERIC tory therapists), multidisciplinary (same professions but different
via EBSCO (1907 to present), ProQuest ABI/INFORM Collec- disciplines, such as surgical and anesthesiology learners), or
tion (1971 to present), and [Link] (1999 to present). neither. We defined learning and debriefing group size as indi-
The searches were conducted in April 2022. The PICO ques- vidual, dyad (2 learners), medium (3–5 learners), and large
tion for this review was defined as “In healthcare providers (>5 learners) as per Salas et al.54 Task complexity was rated as
[P], does the use of one debriefing or feedback intervention low (a simple psychomotor task like chest compressions), me-
[I], compared to a different debriefing or feedback interven- dium (a more complex or more cognitively challenging task,
tion [C], improve educational and clinical outcomes [O] in such as management of a stable arrhythmia), and high (crisis
simulation-based education?” management in a polytrauma patient). The structure of the de-
The search strategy incorporated controlled vocabulary and brief was also assessed using a framework described by Keiser
free-text synonyms for the concepts of improvement, teams, and Arthur27 in their meta-analysis on debriefs. A debrief was
training, debriefing, comparison, and simulation. The full da- determined to follow a high administrative structure if each
tabase search strategies are documented in Supplementary debriefing in the study followed a specified set of steps. For ex-
Digital Content (see Table, Supplemental Digital Content 1, ample, if each debrief in the study used the PEARLS framework
Search Strategy, [Link] No restrictions and went through each of the 4 stages (reactions, description,
on language or other search filters were applied. All identi- analysis, summary), it was rated as having high administrative
fied studies were combined and deduplicated in a single ref- structure. Similarly, each debrief's content structure was ap-
erence manager (EndNote, Clarivate) and then uploaded into praised. If each debrief in the study contained the same content
Covidence systematic review software (Covidence, Veritas Health (such as team work, or a focus on a particular medical proce-
Innovation). dure), the study was rated as having high content structure.27
Inclusion and Exclusion Criteria Quality Assessment
All primary research publications were included compar- For each study, 2 authors, one of which was one of the lead
ing one form of debriefing or feedback with another in a health- authors, independently assessed study quality using the Medical
care simulation teaching intervention. Synthesis articles, systematic Education Research Study Quality Instrument (MERSQI)
reviews, and meta-analysis were reviewed for appropriate ref- tool.7,55,56 It includes 10 items assessing study design, sampling,
erences. Editorials, research protocols, abstracts, and reports type of data collected, validity, data analysis, and outcomes.
of conference presentations were excluded. We also excluded
articles in which feedback was provided by a device, such as Statistical Analysis
a CPR feedback device (augmented feedback), as we wanted We report descriptive statistics of the studies in the dataset.
to focus on the approaches performed by facilitators. Given the heterogeneous nature of the included studies, we
elected not to perform a meta-analysis.
Data Screening
Using Covidence, 2 authors (J.P.D. and M.K.) indepen- RESULTS
dently screened and reviewed titles and abstracts in duplicate. Results of the Search
They discussed results with the larger review team and solved We performed our search in April 2022. We retrieved a total
disagreements through discussion. Four authors (K.M., J.C.S., of 1604 citations, reducing them to 1572 after removal of dupli-
J.P.D., M.K.) reviewed the full texts to identify articles for data cates. After title and abstract screening, we selected 110 articles for
extraction. Each article was reviewed by 2 authors indepen- full-text review with 70 included in the systematic review (Fig. 1).
dently. Consensus was achieved by discussion. When that was The full list of articles in the data set is included in Supple-
not possible, the article was reviewed by one of the lead authors mentary Digital Content 3 table (see Table, Supplementary Dig-
(J.P.D. or M.K.) for a final assessment. ital Content 3, included studies, [Link]

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FIGURE 1. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) diagram.

Study Characteristics
Continent and country of origin of the studies in the dataset
is described in Table 1. Four studies (5.8%) did not report the
study origin. Forty-four studies (62.9%) were published in edu- TABLE 1. Geographic Origin of the Studies
cational journals (eg, Simulation in Healthcare, Nurse Educator), No. Studies
Geographic Origin (% of Total Studies; N = 70)
and 26 (37.1%) were published in discipline journals (eg, JAMA
Pediatrics, Surgery). There has been a steady increase in the North America 32 (45.7%)
number of publications with 2 published in 2006 with 15 pub- United States 19 (27.2%)
lished in 2021 (Fig. 2). Canada 11 (15.7%
Both Canada and United States 2 (2.9%)
Type and Quality of Studies Europe 15 (21.4%)
We categorized 56 of the 70 included studies (80.0%) as Germany 6 (8.6%)
randomized controlled trials (RCTs) and 14 (20.0%) as United Kingdom 2 (2.9%)
nonrandomized studies. Most of the studies were single-center France 2 (2.9%)
studies (64 studies; 91.4%), 2 (2.9%) were 2-center studies, and The Netherlands 2 (2.9%)
4 (5.7%) were conducted at 3 or more institutions. In 53 studies Switzerland 1 (1.4%)
Spain 1 (1.4%)
(75.7%), objective measurement was used; 17 (24.3%) relied
Ireland 1 (1.4%)
solely on assessment by participants. In 9 studies (12.9%), sat-
Asia 15 (21.4%)
isfaction, attitudes, perceptions, or opinions were measured; in Korea 9 (12.9%)
59 studies (84.3%), knowledge or skills were measured; and in 1 China 3 (4.3%)
study, each (1.4%) behaviors or patient/health-care related out- Iran 1 (1.4%)
comes were measured, respectively. Adjusted MERSQI scores Japan 1 (1.4%)
[ie, final scores excluding the response rate item due to lack Hong Kong 1 (1.4%)
of reported data; maximal achievable points = 16.5 (instead South America 2 (2.9%)
of 18)] ranged from 6.5 to 14 (median 11). Brazil 1 (1.4%)
Columbia 1 (1.4%)
Participants Studied Australia 1 (1.4%)
Most of the studies were uni-professional with 6 studies Africa 1 (1.4%)
(8.6%) enrolling learners from more than 1 profession (ie, Not reported 4 (5.7%)

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FIGURE 2. Year of publication of the included studies.

medicine and nursing). Of the uni-professional studies, 12 Debriefing Intervention

(17.1%) had learners from different disciplines (ie, anesthesiology Fifty-four of the studies (77.1%) reported a particular
and surgery). The remainder of the 50 studies that reported learner debriefing intervention; 16 (22.9%) did not. Of the 54 studies
characteristics enrolled learners from a single discipline and profes- reporting a particular intervention, 43 (61.4%) reported the
sion. There was a large range of numbers of participants, from use of a debriefing framework (eg, PEARLS, RCDP). One study
12 in 1 study and as many as 450 in the largest with a median of tested the effect of a relaxation phase between simulated case
50 participants in each study. Most studies involved learners, ei- and debriefing and found a benefit.66
ther students (46 studies) or residents/fellows (25 studies), with Debriefing Duration
a minority enrolling postlicensure providers (6 studies). Only 50 studies (71.4%) reported the amount of time
spent in debriefing, which ranged from 10 to 100 minutes
Simulation Interventions (median, 20 minutes).
Half of the studies in the dataset used a mannequin-based Debriefer Characteristics
modality (35 studies). Of the remainder, 12 (17.1%) used a task Few studies reported any details about the number of
trainer, 9 (12.9%) used standardized patients, and 2 (2.9%) debriefers per session, nor their level of training and expertise
used a hybrid of multiple modalities. One study (1.4%) used a with debriefing. Only 29 studies (41.4%) reported that debriefers
screen-based simulation and 1 (1.4%) used an extended reality were trained, whereas 41 (58.6%) did not. Debriefing charac-
technique. Simulation modality was not reported in 9 studies. teristics are reported in Table 2. In 22 studies, who did the
Simulated tasks were rated on task complexity from low (such debriefing was the independent variable, for example compar-
as a basic procedural skill such as CPR, 24 studies), high (such ing self-led with facilitator-led debriefing. Debriefers were con-
as healthcare crisis or resuscitation, 23 studies), and medium tent experts in 31 (44.9%, intervention) and 33 (47.8%, control)
(all other studies, 22 studies). Only 27 studies (38.6%) included studies; their expertise was not reported in 24 (44.3%, inter-
explicitly stated hypotheses, and these rarely went beyond pro- vention) and 22 (31.4%, control) studies.
posing simple main effects.

Study Outcomes Selected Specific Debriefing Interventions

In most cases, outcomes measures were poorly reported. Although there were many different debriefing interventions
Many studies focused primarily on low level Kirkpatrick out- studied in the dataset, there were several that were common—
comes. In 7 studies (10.0%), reactions were used exclusively we report these hereinafter.
as an outcome measure, while 12 studies (17.1%) assessed knowl- Rapid Cycle Deliberate Practice
edge. Skills performance was assessed in 54 studies (77.1%). Seven studies examined the use of RCDP59,67–72; all of these
One study examined a systems-level outcome.57 In this study, were in pediatric or neonatal resuscitation or septic management.
the authors reviewed data from a previous study and deter- Six studies showed an immediate improvement in performance
mined the cost-effectiveness and a willingness-to-pay value in groups taught using a RCDP methodology59,67–69,71,72 though
of instructor-led versus self-debriefing. Eight studies measured this was not consistent in all studies.70 Only one study exam-
any form of retention (ie, any assessment of learning performed ined retention of learning and there was no difference between
after any period had passed from the initial education).58–65 In the RCDP and standard debriefing groups.67 However, inter-
the 32 studies, which looked at dyad/team debriefings, only estingly, the RCDP had the largest decline in assessed perfor-
one (1.4%) controlled for dyad/team membership via multi- mance 4 months after training.
level analysis. Instructor-Guided Versus Self-debriefing
Seventeen studies examined the effect of self or peer-led
Debriefing Interventions debriefing in comparison with an instructor-facilitated debrief,
Despite the studies all examining different debriefing inter- the independent variable being presence of an instructor during
ventions, the actual debriefing or feedback session itself was the debrief (compared with no instructor). In many of these
often poorly described. studies, the learners were provided with a guide (such as specific

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 TABLE 2. Debriefing Characteristics video during a peer-led feedback session improved history
No. Studies (% of Total Studies, N = 70) and informed consent skills in a group of medical students dur-
Intervention Comparison
ing their surgical rotation. One study by Kang and colleagues74
examined the effect of an initial group reflection without an in-
Debriefing timing
structor present followed by an instructor-led debrief compared
After 55 (78.5%) 64 (91.4%)
with a control group that received only an instructor-led debrief
During 15 (21.4%) 5 (7.1%)
Not reported 0 1 (1.4%)
in nursing students. Interestingly, students that were able to dis-
Debriefing group size cuss among themselves before meeting an instructor demon-
Individual 22 (31.4%) 22 (31.4%) strated significant improvement in problem-solving process
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Pairs 5 (7.1%) 5 (7.1%) and debriefing satisfaction compared with those that only had
Medium (2–5 learners) 15 (21.4%) 15 (21.4%) instructor-led debriefing.
Large (>5 learners) 13 (18.6%) 13 (18.6%) Video-Assisted Debriefing
Not reported 15 (21.4%) 15 (21.4%) Nine studies examined the benefits of using video during
Group composition debriefing compared with no video. Results were mixed with 5
Multidisciplinary 6 (8.5%) 6 (8.5%) studies showing no benefit of the addition of video to debriefing
Multiprofessional 12 (17.1%) 12 (17.1%)
sessions in neonatal resuscitation skills,86,87 intravenous (IV)
Not reported 5 (7.1%) 0
medication administration in nursing students,88 or nontech-
No. debriefers
Zero (self ) 14 (20.0%) 10 (14.2%)
nical skills in anesthesia trainees.89 However, other studies
1 debriefer) 25 (35.75%) 27 (38.6%) demonstrated a benefit with the use of video during debriefing
2 debriefers 10 (14.3%) 9 (12.9%) compared with no video. One study found that feedback with
≥3 debriefers 3 (4.3%) 2 (2.9%) video was associated with the largest improvement of novices'
Not reported 18 (25.7%) 22 (31.4%) laparoscopic suturing skills.75 The study by Ruesseler and
Script used 14 (20.0%) 9 (12.9%) colleagues79 mentioned previously found that compared with
Administrative structure oral-only feedback, students receiving video-assisted feedback
High 44 (62.9%) 42 (60.0%) performed significantly better at taking patient histories in
Low 6 (8.6%) 6 (8.6%) surgical students. Grant and colleagues90 found that whereas
Not reported 20 (28.6%) 22 (31.4%)
behavior scores were higher with video than without video,
Content structure
they had no impact on the number of performed nursing be-
High 35 (50.0%) 27 (38.6%)
Low 6 (8.6%) 7 (10.0%)
haviors. Prakash and colleagues91 found better overall and
Not reported 29 (41.4%) 36 (51.4%) nontechnical performance on delayed assessment in the video
Video-assisted group but no differences in technical performance and reac-
Yes 25 (35.7%) 14 (20.0%) tions to the debriefing. One study examined the use of
No 12 (17.1%) 19 (27.1%) first-person video in debriefing but found no significant gains
Not reported 33 (47.1%) 37 (52.9%) in learning outcomes of CPR and teamwork.92

goals,73 a debriefing framework74) or a video (eg, see the stud-

DISCUSSION
ies Halim et al75 and Lee et al76) to facilitate the self-debrief,
with mixed results. Most of the studies used a video of the The aim of this systematic review was to answer the question
simulation,61,65,76–79 a checklist,80,81 debriefing guide82,83 or of whether educational and clinical outcomes in health profes-
exemplar video,84 or some combination of these tools57,75,85 to sions simulation-based education are improved if facilitators
guide the students through their debrief. Only 4 studies on use one debriefing intervention compared with a different
self-debriefing were done on postlicensure learners,57,61,77,85 debriefing intervention. Based on the results of our review,
there is insufficient evidence at present to adequately answer
with the majority of the rest recruiting nursing students. Eight
this question. Our findings highlight that debriefing impact
studies examined higher-level outcomes (such as skill develop-
ment) and results were mixed. Only one study reported a ben- research comprises very few studies with high-quality evidence,
efit of self-debriefing in post-graduate year 1 (PGY-1) interns; very few multicenter studies, and very few studies explicitly
Oikawa and colleagues81 noted that teams that self-debriefed testing a debriefing model with measurable, robust outcomes.
using a scenario-specific checklist and debriefing guide reported However, interest in debriefing research (based on number of
higher teamwork skills on self-assessment. Boet and colleagues77,85 publications) is growing. In what follows, we will highlight
demonstrated no difference in individual or team skills after current debriefing research foci, discuss challenges we see,
and point to future research needs.
self-debrief (guided by video) versus instructor debriefing in
anesthesia residents and teams. In a subsequent analysis of their Current Debriefing Research Foci
data, they also demonstrated a cost-effectiveness of self-debriefing, Much of the current debriefing and feedback variables
the only study in the dataset to examine cost of an intervention.57 examined in simulation research has followed Raemer and
However, other studies examining skill development showed colleague's proposed framework of “who, where, when, what,
improved performance after instructor-led debriefing when why”51 and addressed selected questions around (a) who should
compared with self-debriefs, even when guided by a video or debrief/provide feedback (self, peer, facilitator), or (b) when to
checklist.61,82,84 In a study examining the effect of video on debrief/provide feedback (during or after simulated case), or
self-debriefing, Ruesseler and colleagues79 found that using a (c) with what device (video, script), or (d ) based on what

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 approach (eg, PEARLS). Other independent variables were that will maximize learning. Although it is likely over-simplistic
debriefing duration, group size, and debriefing structure. Sur- to suggest that all learning in simulation occurs in debriefing, it
prisingly, although debriefer expertise and skill are considered is undoubtedly a key component of any simulation intervention.89
crucial in the debriefing literature,13,93 in the studies we re- Learners may recognize behaviors that are successful or unsuc-
viewed, debriefer training and skill level were rarely or super- cessful as they receive feedback during the scenario itself (such
ficially described. Based on our review, we find it hard to draw as vital signs improving on a mannequin as an intervention is
clear-cut conclusions with respect to potential superiority of performed or a standardized patient responding positively to a
any of the studied independent variables because the outcomes line of discussion), but cementing that knowledge with some
they were tested against were mostly reactions, attitudes, or se- form of reflection is likely critical. A recent meta-analysis on
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lected skills. Thus, while we may conclude that some debriefing educational debriefing (ie, after action reviews), which was
methods (eg, instructor-led over self-debriefing) were generally not focused on simulation, highlighted the importance of ex-
favored more than others, we cannot make comparable conclu- ploring task and training characteristics.27 For tasks that offer
sions with respect to their effectiveness. limited intrinsic feedback and of high complexity (eg, manag-
Certain independent variables were emphasized more than ing a simulated, complex trauma), debriefing was associated
others in the studies we reviewed. with higher impact on performance compared with tasks with
Timing of intervention was a common, independent var- more intrinsic feedback and low complexity (eg, simulating
iable which has received more interest in the last few years, chest compressions).27 Such relationships were rarely tested
specifically RCDP-type debriefing frameworks. Since its devel- in the studies we reviewed; not even half of the studies stated
opment by Hunt and colleagues,35 RCDP has been tested in even simple, main effect hypotheses.
multiple domains. Most feedback experts recognize that timely What happens in a debrief or feedback session also has an
feedback is important, and the RCDP model allows facilitators impact. An analysis of debriefing interactions showed that
to step in quickly to correct critical errors rather than waiting combining advocacy with inquiry, asking open-ended ques-
for the end of the event (which could be 15–30 minutes later). tions, and paraphrasing support learner’s reflections, whereas
After a brief coaching session, learners then get an opportunity stand-alone appreciations did not.42 Studies of team decision
to repeat the scenario to apply what they have learned accord- making and meetings—some outside of healthcare—revealed
ing to experiential learning principles.94 Six of 7 studies exam- that what team members do and say during meetings signif-
ining RCDP59,68–70 found a benefit on early skill learning with icantly impacts their performance, for example, decision
2 demonstrating improved retention.71,72 However, more re- quality.96–103 We have limited evidence relating specific inter-
search is required exploring the potential challenges with RCDP actions in a debrief to outcomes.
(eg, the instructor wrongly assuming that the reason the learners Insights into which debriefing interventions are most
are struggling is a knowledge gap). effective to improve educational and clinical outcomes in
The availability of well-trained simulation facilitators can simulation-based education are required to guide debriefing
be a challenge in most programs, so understanding when an facilitators. These insights will inform debriefing faculty devel-
instructor should be present to guide debriefing is important. opment efforts for faculty.104–106 They will also help mitigate
While the presence of an instructor was a second, common inde- workload during debriefing,15 enhance debriefing skills and
pendent variable, self-led debriefing was frequently introduced debriefing quality, and thus contribute to safe patient care.
with the exclusive aim of saving costs rather than educational Studies examining the direct effect of specific debriefing inter-
purpose. Providing some form of structure to the self-debrief ventions that clearly link to outcomes will be helpful in im-
generally improved outcomes compared with self-debriefs with- proving our delivery of simulation-based education. In their
out a guide. work on trauma education, Brazil and colleagues107 examined
The use of video to assist recall during the debrief was a the use of a relational coordination framework in trauma sim-
third, common intervention. Human recall of stressful events is of- ulation and highlighted some of the more subtle changes in
ten poor,95 and the use of short snippets of video to refresh mem- culture that can be enhanced by simulation and debriefing.
ory and point out issues can be powerful. Our review found mixed Without empirical evidence from the healthcare simula-
results. In some studies, the use of video to help learners reflect tion literature to guide us, currently available debriefing tech-
was associated with improved learning outcomes,79,91 but in niques and frameworks have been pulled from educational
others, there was no significant improvement with the addi- and other social sciences research. However, there are signs
tion of video.86–89 Like many debriefing interventions, it is likely from that literature that currently established practices in sim-
that there are specific contexts in which video-assisted debrief can ulation debriefing may not be effective. As an example, Keiser
and should be used, but more work is needed to elucidate these. and colleagues27 in their meta-analysis found that debriefings
were less effective when they included an initial reactions phase,
Current Gaps and Challenges a key component in many debriefing frameworks (though not
In 2011, Raemer and colleagues52 identified large gaps in all, such as the Diamond model).33 We are not aware of any em-
the simulation debriefing literature. They noted at the time pirical evidence in healthcare simulation debriefing of the role
that research in the area was sparse despite a widespread belief of the reactions phase. However, as discussed in the results,
that debriefing is a key component in simulation-based learn- one study demonstrated the benefit of a “relaxation phase” be-
ing. Over 10 years later, there has been little change in the fore debriefing. Studies like this are important as they demon-
debriefing research landscape, which remains a major challenge strate how very simple and feasible changes in our debriefing
to simulation educators as we attempt to develop interventions strategies can have large impacts on learning outcomes.

Vol. 19, Number 1, IMSH Research Summit Supplement 2024 © 2023 Society for Simulation in Healthcare S117
Copyright © 2024 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
 One of the largest challenges we face is poor reporting. 4. Cook DA, Brydges R, Hamstra SJ, et al. Comparative effectiveness of
Even in studies that were explicitly studying a debriefing inter- technology-enhanced simulation versus other instructional methods: a
systematic review and meta-analysis. Simul Healthc 2012;7(5):308–320.
vention, details of the intervention that would allow replica- doi:10.1097/SIH.0b013e3182614f95.
tion of the study were missing. The publication of reporting
5. Eppich WJ, Hunt EA, Duval-Arnould JM, Siddall VJ, Cheng A.
frameworks in simulation-based research108 will hopefully help Structuring feedback and debriefing to achieve mastery learning goals.
this issue, although it is important that authors and editors refer Acad Med 2015;90:1501–1508. doi:10.1097/acm.0000000000000934.
to the framework to ensure adequate details are present. With 6. Cheng A, Grant V, Robinson T, et al. The Promoting Excellence and
the large number of potentially influencing variables, each with Reflective Learning in Simulation (PEARLS) approach to health care
the challenges of operationalization and measurement, under- debriefing: a faculty development guide. Clin Simul Nurs 2016;12(10):
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standing how debriefing can influence outcomes will be diffi-
7. Cheng A, Eppich W, Grant V, Sherbino J, Zendejas B, Cook DA.
cult. What might be a good intervention in one context might
Debriefing for technology-enhanced simulation: a systematic review and
not be helpful in another, even where there may be only subtle meta-analysis. Med Educ 2014;48:657–666. doi:10.1111/medu.12432.
differences between the two. 8. Cheng A, Hunt EA, Donoghue A, et al. EXPRESS—examining pediatric
Study Strengths and Limitations resuscitation education using simulation and scripting. The birth of an
international pediatric simulation research collaborative–from concept to
Studying debriefing can be a challenge, with multiple var- reality. Simul Healthc 2011;6(1):34–41. doi:10.1097/SIH.
iables in play. Some of these can be measured (learner training 0b013e3181f6a88701266021-201102000-00008 [pii].
level, debriefing framework), but many are more difficult to 9. Sawyer T, Eppich W, Brett-Fleegler M, Grant V, Cheng A. More than one
assess (learner/debriefer emotional state, tone of questioning, way to debrief: a critical review of healthcare simulation debriefing
debriefer-learner interactions, cultural implications). This com- methods. Simul Healthc 2016;11:209–217. doi:10.1097/sih.
0000000000000148.
plexity makes summing up this literature especially difficult. We
have done our best to mitigate this by gathering a large group of 10. Rudolph JW, Simon FB, Raemer DB, Eppich WJ. Debriefing as formative
assessment: closing performance gaps in medical education. Acad Emerg
experts (both within clinical simulation and outside of it) with Med 2008;15:1010–1016.
diverse academic and geographic backgrounds to review studies 11. Rudolph JW, Foldy EG, Robinson T, Kendall S, Taylor SS, Simon R.
and our results. Not only were relevant simulation and debriefing Helping without harming. The instructor's feedback dilemma in
variables extracted from the data, but the quality and risk of debriefing—a case study. Simul Healthc 2013;8:304–316.
bias of included studies were also assessed. 12. Seelandt JC, Walker K, Kolbe M. “A debriefer must be neutral” and other
However, one of the large limitations of our study is sec- debriefing myths: a systemic inquiry-based qualitative study of taken-for-
granted beliefs about clinical post-event debriefing. Adv Simul (Lond)
ondary to the state of the currently available literature. There 2021;6(1):7. doi:10.1186/s41077-021-00161-5.
are few high-quality empiric studies that would allow us to pro-
13. Cheng A, Eppich W, Kolbe M, Meguerdichian M, Bajaj K, Grant V. A
vide any clear recommendations on best practice in debriefing conceptual framework for the development of debriefing skills: a journey
in simulation education. In addition, there were large gaps in of discovery, growth, and maturity. Simul Healthc 2020;15(1):55–60. doi:
reporting in the included studies, making extraction challenging. 10.1097/sih.0000000000000398.
14. Sweeney RE, Clapp JT, Arriaga AF, et al. Understanding debriefing: a
CONCLUSIONS qualitative study of event reconstruction at an academic medical center.
Debriefing and feedback are important components of simulation- Acad Med 2020;95(7):1089–1097. doi:10.1097/acm.0000000000002999.
based education. Despite this, our current debriefing strategies, 15. Fraser KL, Meguerdichian MJ, Haws JT, Grant VJ, Bajaj K, Cheng A.
frameworks, and techniques are not based on robust empirical Cognitive load theory for debriefing simulations: implications for faculty
development. Adv Simul (Lond) 2018;3:28. doi:10.1186/s41077-018-
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ACKNOWLEDGMENT
The authors thank the 2023 Society for Simulation in Healthcare 17. Allen JA, Reiter-Palmon R, Crowe J, Scott C. Debriefs: Teams learning
Research Summit participants who reflected on our results and provided from doing in context. Am Psychol. 2018;73:504–516. doi:org/10.1037/
valuable insights. The authors also thank Dr Rachel Elkin for her final re- amp0000246
view of the manuscript. 18. Phillips EC, Smith SE, Tallentire V, Blair S. Systematic review of clinical
debriefing tools: attributes and evidence for use. BMJ Qual Saf 2023. doi:
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