In Situ Debriefing in Medical Simulation


First described in the anesthesia literature in the late 1980s, medical simulation has become an essential part of training in medical education at the undergraduate and graduate level, as well as in nursing and pharmacy education.[1][2] Traditionally, simulation occurs in dedicated simulation centers. This center-based simulation offers the benefit of being separate from patients and focusing on learning for the individual and the team.[3] Dedicated time is scheduled to participate in this educational activity, and debriefing of the simulation can take part without competing demands of the clinical work environment.

 In situ simulation differs from a center-based simulation in that it occurs in the actual clinical environment, often using providers and staff who are currently on shift. Because it occurs in the real working environment, it provides opportunities for learning on the unit and organizational level as well.[3] In situ simulation has been used to improve teamwork and communication, as well as helping to identify systems issues and latent patient safety threats.[4][5][6][7] In situ simulations, such as mock codes, may ultimately improve patient outcomes.[8]


Experiential learning is the pillar of adult learning theory, which posits that learners gain knowledge from participating in and reflecting upon real-life experiences.[9] A medical simulation provides a concrete experience as a starting point, but analysis and reflection is a required step in the learning cycle. Debriefing, which is an analysis of an event that allows learners to reflect on their experience and make meaning of it, is a frequently used tool in medical simulation, as self-directed reflection may be unsystematic or absent.[10] Instead, a facilitated debriefing is often needed to guide participants through this reflective process.[10]

Many models of debriefing have been described in the literature.[11] Some focus on understanding the participants’ frames of reference.[12] Others address participant emotions before entering into an analysis phase.[11] One theme common among all methods is that facilitated reflection takes time. While time may be more plentiful in scheduled, center-based simulation debriefing, it is often more limited in the in situ setting.

Curriculum Development

There is currently no “gold standard” for conducting a post-simulation debriefing in either center-based settings or in situ settings. A review of trends for in situ simulations suggests the majority of in situ simulation debriefings use post-simulation facilitated debriefings (55%) or facilitated debriefings combined with a review of video taken during the simulation itself (31%).[3]

Some authors recommend learner self-assessment or directive feedback as the primary method for in situ simulation debriefing; this allows facilitators to address more topics with limited time.[13] Due to the constraints of a real working environment, the times allotted to in situ debriefings may be less than in center-based environments. Nevertheless, the minimum amount of time needed for a debriefing is equal to the scenario length itself.[14] 

Learner Self-Assessment

A common learner self-assessment model of debriefing is the Plus/Delta model.[10][15] In this method, the debriefer encourages participants to actively perform their self-assessments, identifying things that went well (the "plus") or things that could have been better (the "delta").[13] Using open-ended questions, the facilitator may then probe participants to identify potential alternatives or solutions to issues raised in the simulation. This plus/delta method may be effective when the primary focus of the debriefing is addressing communication or systems issues that arose during the simulation. 

Another form of learner self-assessment is the SHARP method.[16] Initially created to debrief events in the operating room, in this model, participants describe what went well (or not) and why. The acronym "SHARP" stands for:

1. Set learning objectives: Determine what learners want to obtain from participating in the case and what the educator's goals are2. Ask, "How did it go?": Ask students to self-identify areas of strength and weakness. 3. Address concerns: Discuss with students where improvements are possible.4. Review specific teaching points: This can include basic science and pathophysiology to students' communication and teamwork. 4. Plan ahead: Have students identify what they will take away from the case and incorporate it into their practice.[16]

Because the SHARP method includes both opportunities for teaching as well as incorporation into clinical practice, it may be a useful tool for in situ simulation debriefs.

 Directive Feedback

Directive feedback is a form of feedback that does not depend on the assessment learners make of their own performance.[10][17] Instead, it is unidirectional, with the facilitator sharing his or her assessment. This may be useful when the primary focus of the debriefing is to address a knowledge gap or performance gap, such as in procedural skills training.[17] It may also be used to clarify key learning objectives or with more novice learners.[13][18] Directive feedback does not rely on introspection or self-reflection and is not appropriate when the primary simulation objectives are teamwork-based.[19]

 Conversational Models

Despite time constraints, facilitators are not limited to these learner self-assessment or directive feedback models. Conversational models of debriefing have been successful with in situ simulations. Facilitators have successfully used the “debriefing with good judgment” model during in situ debriefings while maintaining a short simulation-to-debriefing time ratio.[4] In this model, facilitators conduct a phased conversation with learners, where facilitators analyze and discuss events and then intentionally move to a summary phase where participants discuss the application of what the student learned.

The advocacy-inquiry model (AIM) is another conversational debriefing model that seeks to understand a participant’s underlying thought process. This form of debriefing, though not specific to the in situ setting, is preferred by learners who are farther along in their training and thus may be more applicable to the varied experience levels in the in situ team.[18] It also encourages participants to challenge their own decision making and underlying beliefs.[18] In this method, the debriefer begins with a statement that represents the advocacy portion: “I noticed that you did [specific action]. I am concerned that this may cause [specific outcome].” By linking the specific action to its resulting outcome, feedback may be more specific, and learners may better associate the consequences of particular actions.[18] The debriefer then seeks to understand the participant’s frame with the inquiry portion, for example, asking, “Can you help me understand where you were coming from?”

Multiple other conversational models exist, as do blended models. The “Promoting Excellence And Reflective Learning in Simulation” (PEARLS) method is an example of a blended model, which combines learner self-assessment with focused facilitated discussion and directive feedback.[20]

Clinical Clerkships

All debriefing methods are appropriate to use for learners across various levels of training and specialties. 

Continuing Education

Several tools exist to aid in the evaluation of the debriefing itself. These include the Debriefing Assessment for Simulation in Healthcare (DASH) and the Objective Structured Assessment of Debriefing (OSAD).[21][22] These tools are not specific to either center-based or in situ debriefing.

Clinical Significance

The popularity of simulation is continuously increasing as a model of experiential learning that is preferred by adult learners. Debriefing is an intrinsic component of the simulation exercise to ensure meaningful teaching points. The approaches to debriefing are variable and can be adapted depending on the environment and the needs of the learners. 

Written tools, such as the PEARLS debriefing tool, attempt to provide structure to the debriefing process in the form of a script and a guide.[20] The TEAM Debrief Tool has been shown to increase the amount of learner self-assessment and decrease the amount of directive feedback during debriefings.[19] Novice facilitators may benefit more from formal tools or scripts for their debriefings.[23]

Pearls and Other Issues

  1. Debriefing needs to occur following simulation exercises to be effective. 
  2. The scheduled debriefing time should be for at least the anticipated duration of the simulation exercise. For example, a 10-minute simulation will need at least a 10-minute debriefing. 
  3. Learner self-assessment, facilitator directed feedback, and conversational feedback is three options that facilitators can use to address their feedback. These methods can be blended to best suit the needs of the simulation. 
  4. Reflective observation is an opportunity for simulation participants to reflect upon and evaluate their performance. 
  5. The Advocacy Inquiry Method (AIM) seeks to understand the underlying reason a simulation participant performed a particular action. 
  6. Directive feedback is a useful technique when addressing a gap in procedural knowledge, but maybe less preferred by learners than other models.
  7. Novice facilitators will need support to be proficient at debriefing simulation exercises. Written tools or formal training can provide a framework for a debriefing for novice facilitators. 

Enhancing Healthcare Team Outcomes

In situ simulation has been shown to improve teamwork[4][5] and communication.[6] Essential to successful simulation is quality debriefing. An ineffective debriefing may fail to help learners close a knowledge or performance gap.[24] When debriefing is done poorly or gets perceived as critical instead of constructive, it can lower self-esteem.[25] It may also create anger or resistance, which can undermine the teamwork aspect of healthcare.[25]

Article Details

Article Author

Kimberly Schertzer

Article Editor:

Laryssa Patti


9/23/2020 8:55:44 AM



Gaba DM,DeAnda A, A comprehensive anesthesia simulation environment: re-creating the operating room for research and training. Anesthesiology. 1988 Sep;     [PubMed PMID: 3415018]


Alt-Gehrman P, Nursing Simulation and Transfer of Knowledge in Undergraduate Nursing Programs: A Literature Review. Nursing education perspectives. 2019 Mar/Apr;     [PubMed PMID: 30148759]


Rosen MA,Hunt EA,Pronovost PJ,Federowicz MA,Weaver SJ, In situ simulation in continuing education for the health care professions: a systematic review. The Journal of continuing education in the health professions. 2012 Fall;     [PubMed PMID: 23280527]


Auerbach M,Roney L,Aysseh A,Gawel M,Koziel J,Barre K,Caty MG,Santucci K, In situ pediatric trauma simulation: assessing the impact and feasibility of an interdisciplinary pediatric in situ trauma care quality improvement simulation program. Pediatric emergency care. 2014 Dec;     [PubMed PMID: 25407035]


Miller D,Crandall C,Washington C 3rd,McLaughlin S, Improving teamwork and communication in trauma care through in situ simulations. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2012 May;     [PubMed PMID: 22594369]


Daniels K,Auguste T, Moving forward in patient safety: multidisciplinary team training. Seminars in perinatology. 2013 Jun;     [PubMed PMID: 23721769]


Couto TB,Barreto JKS,Marcon FC,Mafra ACCN,Accorsi TAD, Detecting latent safety threats in an interprofessional training that combines in situ simulation with task training in an emergency department. Advances in simulation (London, England). 2018;     [PubMed PMID: 30505467]


Josey K,Smith ML,Kayani AS,Young G,Kasperski MD,Farrer P,Gerkin R,Theodorou A,Raschke RA, Hospitals with more-active participation in conducting standardized in-situ mock codes have improved survival after in-hospital cardiopulmonary arrest. Resuscitation. 2018 Dec;     [PubMed PMID: 30261220]


Yardley S,Teunissen PW,Dornan T, Experiential learning: transforming theory into practice. Medical teacher. 2012     [PubMed PMID: 22288996]


Fanning RM,Gaba DM, The role of debriefing in simulation-based learning. Simulation in healthcare : journal of the Society for Simulation in Healthcare. 2007 Summer;     [PubMed PMID: 19088616]


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. Simulation in healthcare : journal of the Society for Simulation in Healthcare. 2016 Jun;     [PubMed PMID: 27254527]


Rudolph JW,Simon R,Dufresne RL,Raemer DB, There's no such thing as     [PubMed PMID: 19088574]


Cheng A,Grant V,Dieckmann P,Arora S,Robinson T,Eppich W, Faculty Development for Simulation Programs: Five Issues for the Future of Debriefing Training. Simulation in healthcare : journal of the Society for Simulation in Healthcare. 2015 Aug;     [PubMed PMID: 26098492]


Abatzis VT,Littlewood KE, Debriefing in Simulation and Beyond. International anesthesiology clinics. 2015 Fall;     [PubMed PMID: 26397791]


Eppich WJ,Hunt EA,Duval-Arnould JM,Siddall VJ,Cheng A, Structuring feedback and debriefing to achieve mastery learning goals. Academic medicine : journal of the Association of American Medical Colleges. 2015 Nov;     [PubMed PMID: 26375272]


Ahmed M,Arora S,Russ S,Darzi A,Vincent C,Sevdalis N, Operation debrief: a SHARP improvement in performance feedback in the operating room. Annals of surgery. 2013 Dec;     [PubMed PMID: 23478533]


Hatala R,Cook DA,Zendejas B,Hamstra SJ,Brydges R, Feedback for simulation-based procedural skills training: a meta-analysis and critical narrative synthesis. Advances in health sciences education : theory and practice. 2014 May;     [PubMed PMID: 23712700]


Timmis C,Speirs K, Student perspectives on post-simulation debriefing. The clinical teacher. 2015 Dec;     [PubMed PMID: 26032755]


Thompson R,Sullivan S,Campbell K,Osman I,Statz B,Jung HS, Does a Written Tool to Guide Structured Debriefing Improve Discourse? Implications for Interprofessional Team Simulation. Journal of surgical education. 2018 Nov;     [PubMed PMID: 30093336]


Eppich W,Cheng A, Promoting Excellence and Reflective Learning in Simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simulation in healthcare : journal of the Society for Simulation in Healthcare. 2015 Apr;     [PubMed PMID: 25710312]


Brett-Fleegler M,Rudolph J,Eppich W,Monuteaux M,Fleegler E,Cheng A,Simon R, Debriefing assessment for simulation in healthcare: development and psychometric properties. Simulation in healthcare : journal of the Society for Simulation in Healthcare. 2012 Oct;     [PubMed PMID: 22902606]


Arora S,Ahmed M,Paige J,Nestel D,Runnacles J,Hull L,Darzi A,Sevdalis N, Objective structured assessment of debriefing: bringing science to the art of debriefing in surgery. Annals of surgery. 2012 Dec;     [PubMed PMID: 22895396]


Cheng A,Hunt EA,Donoghue A,Nelson-McMillan K,Nishisaki A,Leflore J,Eppich W,Moyer M,Brett-Fleegler M,Kleinman M,Anderson J,Adler M,Braga M,Kost S,Stryjewski G,Min S,Podraza J,Lopreiato J,Hamilton MF,Stone K,Reid J,Hopkins J,Manos J,Duff J,Richard M,Nadkarni VM, Examining pediatric resuscitation education using simulation and scripted debriefing: a multicenter randomized trial. JAMA pediatrics. 2013 Jun;     [PubMed PMID: 23608924]


Rudolph JW,Simon R,Raemer DB,Eppich WJ, Debriefing as formative assessment: closing performance gaps in medical education. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2008 Nov;     [PubMed PMID: 18945231]


Baron RA, Negative effects of destructive criticism: impact on conflict, self-efficacy, and task performance. The Journal of applied psychology. 1988 May;     [PubMed PMID: 3384772]