The 3D Model of Debriefing: Defusing, Discovering, and Deepening

Abstract

The experiential learning process involves participation in key experiences and analysis of those experiences. In health care, these experiences can occur through high-fidelity simulation or in the actual clinical setting. The most important component of this process is the postexperience analysis or debriefing. During the debriefing, individuals must reflect upon the experience, identify the mental models that led to behaviors or cognitive processes, and then build or enhance new mental models to be used in future experiences. On the basis of adult learning theory, the Kolb Experiential Learning Cycle, and the Learning Outcomes Model, we structured a framework for facilitators of debriefings entitled "the 3D Model of Debriefing: Defusing, Discovering, and Deepening." It incorporates common phases prevalent in the debriefing literature, including description of and reactions to the experience, analysis of behaviors, and application or synthesis of new knowledge into clinical practice. It can be used to enhance learning after real or simulated events.

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The 3D Model of Debriefing:
Defusing, Discovering, and Deepening
Jason J. Zigmont, PhD,* Liana J. Kappus, MEd,* and Stephanie N. Sudikoff, MD*
,†
The experiential learning process involves participation in key experiences and analysis of
those experiences. In health care, these experiences can occur through high-fidelity
simulation or in the actual clinical setting. The most important component of this process
is the postexperience analysis or debriefing. During the debriefing, individuals must reflect
upon the experience, identify the mental models that led to behaviors or cognitive pro-
cesses, and then build or enhance new mental models to be used in future experiences. On
the basis of adult learning theory, the Kolb Experiential Learning Cycle, and the Learning
Outcomes Model, we structured a framework for facilitators of debriefings entitled “the 3D
Model of Debriefing: Defusing, Discovering, and Deepening.” It incorporates common
phases prevalent in the debriefing literature, including description of and reactions to the
experience, analysis of behaviors, and application or synthesis of new knowledge into
clinical practice. It can be used to enhance learning after real or simulated events.
Semin Perinatol 35:52-58 © 2011 Elsevier Inc. All rights reserved.
KEYWORDS debriefing, experiential learning, high-fidelity simulation, postexperience analysis
The key components of simulation-based learning in
health care are the simulated experiences and subse-
quent “post-experience analysis” or debriefing.1Simulation
alone will not facilitate learning; rather, it provides opportu-
nity for learning if debriefed skillfully. This feedback on the
simulation is the most important component of simulation-
based education.2-6 For learning to take place, individuals
must actively reflect upon the experience, identify the mental
models that led to behaviors or cognitive processes, and then
build or enhance new mental models to be used in future
experiences.7-10
Debriefing has historically been practiced in the military to
recap events and strategize for future events, in psychology to
inform participants after deception studies, and after critical
incidents to reduce stress.5,11-13 However, a paucity of litera-
ture exists in the educational arena on debriefing with the
goal of learning from an experience.14 We report on a frame-
work to facilitate learning from experience (simulated or real)
entitled the 3D Model of Debriefing: Defusing, Discovering
and Deepening. The 3D Model is a process based on common
phases prevalent in the debriefing literature and taught at the
Institute for Medical Simulation, Cambridge, MA, including
description of and reactions to the experience, analysis of
behaviors, and application or synthesis of new knowledge
into clinical practice. It incorporates widely accepted debrief-
ing facilitation strategies from health care simulation, avia-
tion, and psychology.5,14 –16 This model is based on strong
adult learning theory and facilitates all aspects of the Experi-
ential Learning Cycle and the Learning Outcomes Model
(Fig. 1,Table 1).9,17,18 The goal of the 3D Model is to help
debriefers facilitate learning to improve daily practice and
patient outcomes.
For learning to be effective and ultimately change practice,
educators must consider the immersive relationship that ex-
ists between learning and factors related to: the individual
learner, the learning experience, and the environment in
which learning occurs (Fig. 1,Table 1).19 Key attributes of
each component related to the 3D Model of Debriefing are
described to follow.
The Individual
In health care simulation, adults are the learners. According
to adult learning theory, there are several key differences to
consider between adults and children and how they learn: (1)
Adults are self-regulated meaning that they decide what and
*SYN:APSE Simulation Center, Yale New Haven Health System, New
Haven, CT.
†Department of Pediatrics, Yale University School of Medicine, New
Haven, CT.
Address reprint requests to Jason J. Zigmont, PhD, SYN:APSE Simulation
Center, Yale New Haven Health System, 730 Howard Ave, New Haven,
CT 06519. E-mail: jason.zigmont@ynhh.org
52 0146-0005/11/$-see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1053/j.semperi.2011.01.003

Author's personal copy
when they want and need to learn,20 (2) adult learners are
intrinsically motivated, often by their self-efficacy or their
belief in their ability to complete a task, their feelings of
competence and their psychological safety,21–23 (3) adult
learners have prior knowledge and experience that form
mental models that guide behavior and cognitive process-
ing,8,9,17,24 and (4) adults use analogical reasoning in learning
and practice.18,25,26 For this work, the individual is referred to
as the participant or learner.
The Experience
Kolb’s Experiential Learning Cycle suggests that active par-
ticipation or having a “concrete experience” is an important
factor in effective learning.9This experience should be con-
sidered alongside one’s previous experience and connections
must be made to future experiences.7These connections can
be discussed in a postexperience debriefing. For the debrief-
ing to be fruitful, the experience must be based on learning
objectives that are practical, useful for the individual, and
relevant to practice. In addition, the experience should have
an impact, ie, adequately challenge the participants or invoke
emotion.4,5,27
Environment
Educators must consider both the learning environment and
the larger clinical environment to promote effective learning.
The learning environment, ie, the classroom or laboratory
setting, should be a place where the adult, self-regulated,
intrinsically motivated individual feels safe to practice, exper-
iment and discuss openly and honestly.6,20,28,29 In addition,
educators must consider the larger clinical environment and
how it affects new learning, experimentation, and sustained
practice change. For the purposes of this work, we will refer
to the learning environment as the microenvironment and
the clinical environment as the macroenvironment.
The 3D Model
The 3D Model (Table 2) is designed to address the individual,
the experience and both the micro- and macro-environ-
ments. The model has 3 distinct parts: Defusing, Discovering
and Deepening and is preceded by a Pre-briefing or introduc-
tion to the process and ends with a Summary of lessons
learned. The Pre-briefing outlines the ground rules for the
debriefing session and sets the stage for learning in the mi-
croenvironment.6,14,30 Defusing is designed to help the indi-
vidual voice the impact of the experience and clarify the
events so that they are ready for reflection.5,6,14-16 Discovering
facilitates “reflective observation” and “abstract conceptual-
ization” (AC) of the experience to help the learner develop-
mental models that can be tested during “active experimen-
tation.”9Deepening helps the learner connect new learning to
potential changes in practice within a greater context, ie, the
macro-environment.14,15 Finally, a brief Summary of key ob-
jectives and lessons learned closes the debriefing.30
Setting the
Learning Microenvironment
The first step in facilitating effective adult learning is creating
a microenvironment that supports learning. This environ-
ment should be established at the beginning of a simulation-
based course or even before the course day with a written
description of goals and expectations. Adult learners must
feel that the environment is safe and focused primarily on
learning before they will be able to actively reflect on and
share their experiences with others.6,28 To achieve this, facil-
itators should clearly articulate that the goals of the session
are self-reflection and learning, not assessment. In addition,
facilitators should set the expectations for the course, includ-
ing ground rules for participating in the scenarios and main-
taining the confidentiality of individual performance and
group discussions. Participants should be asked to engage in
the “fiction contract,” ie, an informal agreement between ed-
ucators and learners to commit to making the experience real
and relevant.31,32 The learners must understand that it is safe
to make mistakes, and encouraged to honestly talk about
them within the confines of the course structure.
If the goal of the course is to assess competence, the safe
environment is compromised. Adult learners are less likely to
talk openly about their weaknesses if they feel they are being
judged. Simulation can be used as a tool for competency
assessment, but assessment should occur completely sepa-
rate from education or learning. Ideally, any assessment
should occur at a different time from the learning opportu-
nities and new rules specified when the simulations “change”
from learning to assessment.
Figure 1 Learning Outcomes Model. For effective learning to take
place, educators must consider the relationships between the indi-
vidual learner, their key experiences, and the learning environment.
The 3D model of debriefing
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Pre-Briefing
As a prelude to the debriefing session, the pre-briefing should
state the process for debriefing so the learner knows how to
participate. McDonnell et al30 describe that introduction to
process increases the depth of participation among learners.
Facilitators should: (1) State the general objectives of the
simulation experience; (2) clarify the role of the instructor as
a “facilitator of learning” who will help guide the discussion
rather than a “teacher;” (3) detail expectations for participa-
tion in the debriefing, and encourage participants to be ac-
tively involved in the process by reflecting upon and analyz-
ing performance; and (4) outline the format that the
debriefing will follow.
Defusing
The Defusing phase follows the simulation and Pre-briefing;
the facilitators should prompt discussion surrounding the
emotional impact of the experience on the learners and the
description of the event and how it unfolded.5,14-16 the pur-
pose of discussing the impact and unleashing emotions is
2-fold: (1) to reduce any anxiety and stress and allow the
Table 1 3D Model Components.
Kolb’s Experiential
Learning Cycle 3D Model Components Learning Outcomes Model
Concrete experience Creating a safe environment
●Introductions
●Ground rules and expectations
●Confidentiality
●Orientation to simulation environment
Individual
●. . . feels “safe”
●. . . knows what to expect
●. . . is prepared to complete
the task
Simulation exercise
●Define objectives
●Enhance realism: care-team, environment,
progression
●Challenging to invoke emotional response
Experience
●. . . creates a change in body
state for individual
●. . . is realistic to evoke
emotion for individual
●. . . is relevant, practical and
useful to individual
Pre-briefing
●Ground rules
●Set expectations
●Explain format
Individual
●. . . knows what to expect
Environment (micro)
●. . . is safe for learning
Reflective observation Defusing
●Discuss emotions
●Recap events
●Conduct Needs Assessment
Individual
●. . . distresses to set stage for
learning
●. . . engages in student-
centered learning
Discovering
●Prompt reflection through objective
observation and video review
Individual on Experience
●. . . analyzes behaviors and
intended outcomes
Abstract conceptualization ●Discover mental models guiding behavior
●Discuss target mental models
●Cue analogical reasoning
Individual
●. . . uses “analogical rea-
soning” to compare exis-
ting mental model to target
mental model
Active experimentation Deepening
●Prompt individual to apply new information
to practice
Individual within
macroenvironment
●. . . mentally connects target
mental model to practice use
within larger clinical envir-
onment
Summary
●Restate learning objectives discussed and
lessons learned.
Individual
●. . . leaves with practical and
useful information.
Simulation Exercise 2
●Allow individual to apply new information
Individual within
microenvironment
●. . . actively connects target
The 3D Model of Debriefing is based on Kolb’s Experiential Learning Cycle, Adult Learning Theory, and the Learning Outcomes Model. It
incorporates well-established debriefing phases and addresses the adult learner, key experiences, and the learning environment(s).
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Table 2 3D Model Breakdown
Examples
Prebriefing Purpose: To explicitly state how the learners
should participate in the debriefing and
how you as the instructor will participate.
Points to Include
- Clarify your role as instructor
- Detail your expectations for learner
participation
- Explain the format the debriefing will
follow
- Tell the learners how long the session
will last.
“My role as an instructor is not to evaluate your
performance, but to help facilitate a
discussion and prompt self-reflection.
I expect you to do most of the talking, raise
questions about what was going on, identify
issues, and volunteer your perspectives.
The format of the discussion is as follows: we
are going to debrief in three parts. First, we
will have an opportunity to talk about our
emotions and the impact of the simulation.
Next, we will clarify the clinical details of the
scenario. During the second part, you will
analyze your own performance and evaluate
how well the management of those situations
worked. Our goal during this phase is to
discover your mental model that guided your
behavior and then talk about that mental
model utilizing all the experience in the room.
We will then connect new learning to future
clinical situations. Finally we will summarize
key learning points.
Defusing Purpose: To allow learner to “vent”
emotions. To recap and clarify what
happened during the scenario. To conduct
a needs analysis of objectives important
to the learner.
Points to Include
- Elicit reactions and emotions
- Describe what happened
“How did it feel to be part of that scenario?”
“Thank you for bringing that up....Let’s hold
that thought and come back to it during the
second part of the debriefing.....”
“Let’s recap WHAT happened during that
scenario so that we can then discuss WHY
during the second part of the debriefing.”
Discovering Purpose: To analyze and evaluate
performance through reflection. To
discover mental models or rationale for
specific behaviors through Inquiry. To
identify gaps/matches between existing
and targeted mental models.
Points to Include
- Identify an observed behavior or
outcome
- Ask a question to discover the mental
model guiding that action
- Cue Individual to make/identify analogy/
connection to Target Mental Model
“Person A, I noticed that you did x in y
situation.
I was curious about that action because...
(instructor offers his own mental model about
how to deal with y).
Can you tell me why you did x?”
“Thanks for sharing the rationale. Has anyone
else every experienced this? What did you do
to deal with that situation and why?”
“Person A, how might this situation have been
different if you had used that strategy”.
Or
“Another way to handle x is z (target mental
model). If you had done z, how would that
change y?”
Deepening Purpose: To apply lessons from simulation
and make connections to clinical practice.
“If you were to encounter a similar situation in
the future, how would you handle it?”
Points to Include
- Prompt learner to connect new learning
to larger clinical environment
“How can you use the information we just
discussed in your clinical practice?”
“Can you think of other situations where this
information could be applied?”
Summary Purpose: To review what was learned
throughout the session
Points to Include
- Highlight the key objectives and lessons
learned
“Today we learned the following:.....”
“Let’s end with this...What is one thing that
you can take away from this session to use in
your practice?”
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learner to engage in meaningful discussion13; and (2) to allow
the facilitator to conduct a needs assessment of key points for
discussion. The importance of allowing the participants to
describe or recap the experience is to achieve a shared un-
derstanding of the events of the experience.15
Defusing naturally occurs immediately after the simula-
tion, and participants will often start this process on their
own. As students leave the simulation, they may begin talk-
ing about their experience, providing insight into the feelings
and the simulation provoked. The facilitator should continue
this natural venting process during the Defusing phase.
To launch this part of the debriefing, facilitators should
encourage participants to talk about their feelings, both dur-
ing and after the experience. Every learner does not have to
share their feelings, but they should be given the opportu-
nity. If a safe environment has been set before the experience,
the learner will be more likely to share their feelings. Facili-
tators must consciously guide the discussion to avoid analyz-
ing the experience prematurely. For example, if a participant
begins to analyze the experience before others have had the
opportunity to vent their emotions, or before a description of
the experience has been outlined, a facilitator might say,
“Thank you for bringing up the issue of ‘x.’ This will be
important to discuss, and we will come back to it during the
next phase of the debriefing. However, first, I want to give the
rest of the participants an opportunity to discuss their feel-
ings.”
Asking about feelings has a powerful impact on the learn-
ers. The learners will have just been through a stressful and
emotional simulation (if crafted and implemented well) and
will need to de-stress by releasing emotion. Students may not
be ready to learn until they discuss their feelings, as they may
be too emotionally involved to think clearly or reflect objec-
tively on their experience. The goal is to acknowledge the
feelings and clear the slate for learning.13,27
After this “venting,” it is important to allow participants to
describe the experience so that everyone in the debriefing
session has the same overall understanding of the series of
events and can move from understanding what happened to
why it happened.33 This description should be a discussion of
the facts (ie, clinical management) or a recap of the order of
events. The recap can either come from participants or the
facilitators. During this time, participants may reveal gaps in
knowledge regarding clinical management. This is an oppor-
tunity for content experts to engage in clinical teaching.
This discussion about emotions, impact, and facts during
the Defusing phase will set the tone for analysis during the
Discovering phase. Facilitators must actively listen to the par-
ticipants’ responses and dialogue, as they provide an assess-
ment that highlights key issues for the learners. Individuals
learn more from experiences that cause a change of body
state, or a physical/emotional change. Therefore, when learn-
ers share their emotions, they reveal the moments that caused
the most intense feelings (anger, anxiety, frustration, plea-
sure, pride) and on which they would like to focus. These
moments should be considered part of the learners’ objec-
tives for the debriefing, and can be added into the overall
objectives to promote student-centered learning. This is a
shift from teacher-centered learning during which the in-
structor identifies the learning objectives and, then, imparts
knowledge or the “right way” to accomplish a task.14
Discovering
The second phase, Discovering is based on Steinwach’s “anal-
ogy/analysis” and Kolb’s Experiential Learning Cycle.15 The
goals are (1) to facilitate learners’ engagement in reflective
observation on their own performance and (2) to prompt AC
of new information to build or enhance one’s mental model.9
This requires the facilitator to have keen observation skills
and work with the learner’s mental models to improve the
practice of individuals.
During reflective observation, the facilitator provides an
objective perspective on the experience to help the learner
identify strengths and opportunities for improvement, spe-
cifically related to those points of emotion identified during
Defusing. The facilitator needs to observe the simulation ex-
perience to identify behaviors of the individual and positive
and negative outcomes of these behaviors. The participants
are often unaware of these behaviors while immersed in a
scenario. The video recordings of simulations can be used to
enhance reflective observation by providing an objective,
“third party” view during the debriefing. This triad of infor-
mation, including the facilitators’ observations, the partici-
pants’ recalled experience, and the video depiction, helps
facilitators to guide self-reflection. The aforementioned infor-
mation is the substrate for analysis of behaviors.
This analysis is known as AC, during which learners think
about the events, actions, and outcomes that occurred during
the experience, they then process these ideas to enhance
existing mental models that can be applied in future situa-
tions. During AC, both learner and facilitator must identify
the mental model or decision-making process that led to the
observed action.8,9,16
The learner’s mental model cannot be seen; furthermore,
the learner may not even be aware of the mental model that
led to the action.8,10 The facilitator must maintain a stance of
genuine curiosity throughout the debriefing to avoid making
assumptions about the learners’ mental models.16 The facili-
tator must focus on identifying the learners’ mental model
before any learning can occur.
The key to identifying mental models is to engage the
learner in conversation. Facilitators need to delve deep into
the rationale for certain behaviors through inquiry. Rudolph
et al16 pioneered a tool for identifying mental models or
“frames” called Advocacy/Inquiry. The tool pairs an objective
observation, assertion or statement with an inquiry to probe
for the etiology of individual behavior. Example: “Dr. X, I
noticed that during the delivery, after the mother arrested,
you did not make effort to deliver the fetus until the mother
was stable. I was concerned because it is my understanding
that delivery of the fetus can actually aid the resuscitation of
the mother. Can you tell me why you chose to concentrate
solely on the mother?” In this way, the facilitator alerts the
participant of the observation (either positive or negative be-
havior) and assumes a stance of curiosity as to rationale.
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There is then a 2-way dialogue rather than the more typical
instructor-centered approach. Example: “Dr. X, during a ma-
ternal arrest, to achieve a better outcome for the mother, you
need to deliver the fetus.”
Once the learner has shared their mental model, or the
team has explained their shared mental model, the facilitator
can then identify gaps or opportunities for learning. Identi-
fying the gaps requires the facilitator to compare the learners’
mental model with the expected or target mental model (ie,
newer evidence). If the learner uses an “old” method of treat-
ing a patient and the facilitator is looking to teach a new
method, the gap is the difference in decision making or
knowledge.
In the aforementioned example, Dr. X may offer his mental
model: “I believe that ‘mom is first’ and no effort should be
made to deliver the fetus until the mother is stable.” The
facilitator should then allow time for discussion about this
mental model so the individual can learn. The prior experi-
ence that exists among the group will add to the depth of the
discussion. The facilitator should prompt the learner and, in
fact, all learners in the group to activate their previous expe-
rience with the current topic and compare their own mental
models with the target mental model (ie, delivery of the fetus
aids in resuscitation of the mother and should be undertaken
to save the mother’s life). Target mental models or standards
of practice can be explicitly offered by the facilitator if he or
she is a content expert or can be “discovered” by the group
through discussion.
Once the target mental is revealed, the facilitator should
prompt the learner to engage in analogical reasoning so that
he/she can adapt the mental model for use in future experi-
ences. As Bakken34 describes, when doctors are faced with a
complex diagnosis process, they rely on their previous expe-
riences of “cases” and “counter cases” to help the current
patient. In simulation, this occurs when learners try to com-
pare the current simulation to their previous experiences
inside and outside the simulation arena. Without well devel-
oped mental models to guide decision-making, learners often
make erroneous connections, which may lead to errors. The
most common error occurs when a learner makes a “surface”
connection rather than a “structural” connection. This is
analogous to treating the symptoms rather than the disease.
The symptoms may abate in the short term but will reappear
if the underlying disease is not addressed.
The process of making structural connections between a
past and new patient or experience is analogical reasoning.
Analogical reasoning is the process by which learners adapt
their mental models to apply them to novel experiences, and
improve them for future use.25,26 Facilitators should prompt
participants to recall past experiences that were analogous or
offer analogs that the learner can consider. For example: a
facilitator can ask “how have you handled this situation in the
past?” During this process of comparing, learners are expand-
ing their mental models to incorporate new concepts.
Deepening
Deepening is an explicit connection of the learning (new or
target mental model) to practice (the environment), aka syn-
thesis.15 Ideally, there would be an immediate opportunity
for active experimentation on an actual or simulated patient.
The active experimentation that occurs in the Deepening
phase is an opportunity for the learner to test out their new
mental model and decide whether to keep it.9Without the
chance for immediate experimentation, the learner will have
to attempt to retain the new information until a clinical op-
portunity arises. In most cases, this delay will cause the in-
formation to be lost and the learner to revert back to their old
mental model.
Learners often want to repeat a simulation to try out their
new mental model, especially after the Deepening discussion,
and this should be encouraged. Although it may be difficult
due to time and logistical constraints, learners will get more
out of the simulation by having the opportunity to actively
experiment with their new mental models. The second sim-
ulation should have the same structural issues as the first
simulation and may even be the same simulation. Simply
making small changes (ie, the name of the baby and back-
ground) to allow the learners to practice may be sufficient.
In lieu of a second simulation, Deepening can be facilitated
during the debriefing by prompting the learners to connect
what they just learned to actual practice. A simple strategy is
to ask individuals how they can use the new strategy or
information in actual practice.
At the close of the debriefing, facilitators should provide a
Summary of lessons learned. This should be a brief listing of
the topics that were discussed during the debriefing and so-
lutions or target mental models that were revealed. In this
way, the adult learner leaves feeling that they have learned
information that is practical and useful.30
Conclusions
The individual, their experiences, and both the micro- and
macroenvironments must be considered to effectively
achieve life-long learning.18 Simulation and debriefing are
powerful tools to assist individuals in learning from experi-
ences. When handled skillfully, debriefing is the most impor-
tant aspect of simulation-based education, as it is where the
learning and processing of new information occurs.2-6,14
For adults to learn from experience in the simulated envi-
ronment the individual must feel safe to explore and experi-
ment during the experience, the experience must have an
impact on the individual and highlight learning objectives
that are relevant, and the individual must have the opportu-
nity to reflect on or analyze the experience.5,7,9,29
The 3D Model of Debriefing is a framework based upon
experiential learning theory and common debriefing strate-
gies. It offers a step-wise approach to student-centered learn-
ing. Defusing allows the learner to release emotions and de-
scribe the experience. During this phase, the facilitator
should decide what issues are most important to the learner.
Discovering prompts the learner to identify and analyze the
mental models guiding behaviors and then compare them
with new information introduced by other participants or the
facilitator. During this phase, learners should be encouraged
to use analogical reasoning to apply enhanced mental models
The 3D model of debriefing
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to novel situations. During the Deepening phase, the learner
cognitively applies the new information to the clinical envi-
ronment. Deepening can be enhanced by a second simulation
and reinforced by mentors in the macro-environment.
Although this article was written to address debriefing af-
ter simulated experiences, the 3D model can be and should
be used within the macroenvironment after real events to
reinforce positive behaviors and to allow learners to discover
their own gaps frequently and in real-time. It is this contin-
uous self-reflection, self-discovery and self-improvement
that will ultimately lead to changes in outcomes.35
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