Clinical Simulation in Nursing (2015) 11, 268-275

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Featured Article

Getting Started With Debriefing for Meaningful

Learning
Kristina Thomas Dreifuerst, PhD, RN, CNE, ANEF*
Assistant Professor, School of Nursing, Indiana University, Indianapolis, IN 46202, USA

KEYWORDS Abstract: Debriefing for Meaningful LearningÓ (DML) is a method of debriefing that can be used in
debriefing; simulation environments and other clinical settings to foster student’s reflective thinking and learning.
Socratic questioning; It has been used successfully with prelicensure nursing students, graduate nursing students, and inter-
reflection; disciplinary health care students throughout the nursing curriculum with positive learning outcomes.
clinical reasoning; This method can be challenging to learn because it uses Socratic questioning and principles of active
thinking like a nurse learning to uncover thinking associated with actions, but once learned, DML can be a model for reflec-
tive thinking that students can use to develop clinical reasoning and become reflective practitioners.
Moreover, DML challenges taken-for-granted assumptions in an iterative yet consistent process of
group dialog that students can use long into their practice. This article describes how faculty can
get started using DML and demonstrates the iterative process of the method with examples from simu-
lation debriefing.

Cite this article:

Dreifuerst, K. T. (2015, May). Getting started with debriefing for meaningful learning. Clinical Simula-
tion in Nursing, 11(5), 268-275. http://dx.doi.org/10.1016/j.ecns.2015.01.005.

Ó 2015 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier
Inc. All rights reserved.

There are many ways to debrief prelicensure nursing students. assumptions are common in students as they being to synthe-
Debriefing for Meaningful LearningÓ (DML) is a method of size and apply what they are learning with what they are
debriefing that can be used in simulation environments and experiencing as they apply this new knowledge. Assumptions
other clinical settings to review patient care, cultivate reflec- by the students can be logical and knowledge based or ill
tive thinking, and foster meaningful learning. Optimizing conceived and/or based on one experience that they extrapolate
contextual learning in simulation and traditional clinical set- and therefore take-for-granted to apply to all situations
tings is paramount to the preparation of safe and knowledge- (Jonassen & Easter, 2012). Socratic questioning is an approach
able nurses, but it can be a challenging task for faculty to teaching and learning in which the teacher does not give in-
(Killam & Heerschap, 2013; Norman, Dore, & Grierson, formation or answer students’ questions directly but instead
2012). Through the use of Socratic questioning and guided turns the task of uncovering the answer to the student by asking
reflection, DML can teach students to challenge taken-for- a series of questions so that students come either to the answer
granted assumptions and reveal relationships between or to a deeper awareness of the limitations of their knowledge
thinking and actions (Figure 1). Taken-for-granted (AHDEL, 2011). Socratic questioning often includes the tenets
of inquiry: ‘‘who, what, where, when, how, and why’’ to stim-
ulate reflection and dialog. Socratic questioning includes five
* Corresponding author: [email protected] (K. T. Dreifuerst). general types of questions to help uncover the thinking that

1876-1399/$ - see front matter Ó 2015 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2015.01.005
Starting DML 269

is occurring. These include questions about (a) the underlying

belief or conclusion, (b) opposing thoughts or objections, (c)
the origin or source of the information, (d) the implications
or consequences, and (e) the reasons, evidence, or
assumptions underlying the thought process (Paul & Elder,
2007). DML is grounded in
well-established, construc-
Key Points tivist, and problem-based

Debriefing is a form learning theories and has
of clinical teaching. demonstrated positive stu-

Debriefing for Mean- dent thinking and learning
ingful LearningÓ uses outcomes (Dreifuerst, 2012;
Socratic questioning Hayden, Smiley, Alexander,
to challenge taken- Kardong-Edgren, & Jeffries,
for-granted assump- 2014; Mariani, Cantrell,
tions and uncover Meakim, Prieto, & Drei-
thinking associated fuerst, 2012).
with actions. DML uses six phases for

Debriefing for Mean- debriefing: engage, explore, Figure 1 Challenging taken-for-granted assumptions.
ingful LearningÓ is a explain, elaborate, evaluate,
debriefing method that and extend, in an iterative
uses six phases, yet consistent process of help learners develop important clinical reasoning skills
engage, explore, guided reflection. Through necessary for entry to practice (Dreifuerst, 2010). It was
explain, elaborate, the use of DML, debriefing developed after the author observed numerous simulation
evaluate, and extend, is a form of deliberate clin- debriefings and noted the inconsistencies in debriefing
in an iterative but ical teaching using methods and outcomes (Dreifuerst, 2009). DML has
consistent reflective reflection-in-action, reflec- been successfully used with different levels of prelicen-
process to help teachers tion-on-action (Sch€on, sure nursing students, patient types, and in a variety of
debrief simulation and 1983), and reflection- clinical and simulation settings (Dreifuerst, 2012;
other clinical experi- beyond-action (Dreifuerst, Hayden et al., 2014; Mariani et al., 2012). This debrief-
ences with students. 2010) to teach clinical ing method, grounded in reflection, is easily adapted to
reasoning and thinking like the particular patient situation that the student has
a nurse. DML can be used in all types of simulation and encountered; therefore, the discussion is reflective, pur-
other clinical environments with all patient populations. poseful, and specific.
The phases of DML are guided by a clinical teacher or de- Reflection has been well established as an antecedent to
briefing facilitator who is familiar with the necessary ele- meaningful learning (Mezirow, 2000; Rogers, 2001). More-
ments of care for the patient being discussed and a over, reflective learning translates to amplified capacity for
participant worksheet which together provide a consistent change (Horton-Deutsch & Sherwood, 2008). Although re-
structure to facilitate clinical reasoning in students involved flecting is thought to be an innate experience, not all
in the experience. This article helps the reader to get started learners do it consistently or thoughtfully enough to be a
using DML. significant learning event. Thus, facilitating reflection
through debriefing is essential for helping students get
the greatest benefit from clinical learning in practice and
Background simulation settings (Decker & Dreifuerst, 2012). Moreover,
reflection is a building block for metacognition, a hallmark
Debriefing is an important component of clinical of higher order thinking and clinical reasoning (Pesut,
learning in practice settings and simulation environments 2004). As such, reflective practitioners and expert clini-
(Decker et al., 2013; Dreifuerst, 2009; Shinnick, Woo, cians demonstrate these same thinking skills which are
Horwich, & Steadman, 2011). With limited clinical associated with quality patient experiences and outcomes
time, inconsistent exposure to different types of patients, (Sch€on, 1983).
and variable interactions with faculty, prelicensure stu- DML promotes clinical reasoning by actively teaching
dents may have few opportunities to link classroom con- prelicensure students to use reflection-in-action, reflec-
tent to clinical practice. DML is a method of debriefing tion-on-action, and reflection-beyond-action, along with
that provides consistent opportunities to review clinical assimilation and accommodation (Dreifuerst, 2010;
care, make meaning visible, challenge taken-for- Sch€on, 1983). Reflection-in-action is reflecting in the
granted assumptions, draw out student thinking, and moment while events are occurring. It can be described

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as those times when you can ‘‘see the wheels turning’’ and contextually. All students involved in the simulation,
thinking processes coming together as the student is in the regardless of the role they assumed (including observer),
act of providing patient care. This is different from are actively included as participants in the debriefing
reflection-on-action, which is a retrospective review and discussion.
analysis of events and decision making that occurred pre- A worksheet guides the DML debriefing method and
viously. Reflection-beyond-action highlights the relation- provides visual learning opportunities and double-loop
ship between anticipation and reflection; the students thinking by having the teacher put notes and ideas from the
incorporate what they know or have experienced into an discussion on a whiteboard or smart board (Dreifuerst, 2010).
unfamiliar situation by making links between what is At the same time, participants use their own copy of the work-
known and unknown using anticipation that is informed sheets to create a record of the process which they can take
by reflective thinking. A hallmark of the expert nurse is with them for future review or reference. By encouraging
the ability to anticipate assessment findings based on pa- thinking, seeing, discussing, reading, and writing simulta-
tient information before an actual encounter occurs neously, the worksheet guides the debriefing process through
(Dreifuerst, 2012); this is evident when an expert nurse the use of conceptual mapping. This makes visible the
first hears about a patient. Although not yet seen, she/he thinking relationship among assessment, decisions, and ac-
anticipates encountering based on knowledge and prior tions using the process of reflection and mimics the notes
experiences. Once the patient encounter begins, the nurse the clinical teacher is putting on the whiteboard (Pesut,
then assimilates the components of the experience that fit 2004). Double-loop learning in the DML method can further
the anticipated frame and accommodates. When assimila- be enhanced by the use of different colors of whiteboard
tion is not possible, then accommodation or reframing markers and ink. Often, black is used to record what occurred
must occur as the nurse adjusts thinking and actions to or the students say, red for things that were wrong or could be
address the situation at hand. Reflective practitioners improved on, green for things that were good, correct, and
who engage in introspection learn to self-correct and effective, and blue for new thinking or change.
assimilate new experiences with prior ones and greatly The six phases of DML adapted from the E5 model
improve their professional competence and ability to suc- developed by Bybee et al. (1989) are: engage, explore,
cessfully navigate unfamiliar patient scenarios (Rudolf explain, elaborate, evaluate, and extend. These phases are
et al., 2007). iterative and often overlap during the course of the debrief-
DML facilitates the development of inferential, analytic, ing. However, each is an important component of the
and evaluative thinking processes which build on inductive method as the clinical situation is debriefed with the stu-
and deductive reasoning and elements of clinical reasoning dents. This article gives a real-life example of the phases
that encompass thinking like a nurse (Facione & Facione, of DML (in italics) as it is used in a simulation debriefing
2006; Tanner, 2006). To foster deep thinking, DML uses with prelicensure students.
six concepts consistently wherein teachers and students
reflect on the clinical experience together, make sense of Engage
it, improve understanding, prepare for future clinical en-
counters, and increase clinical reasoning and meaningful During the engage phase of DML, teachers and students
learning. conclude the simulation or other clinical experience and
gather to debrief. The learners transition from the activity
and emotion of clinical care to focus on reflective
Overview of the Debriefing for Meaningful debriefing, analysis, and dialog about the clinical situa-
LearningÓ Method tion. In the initial minutes of debriefing, they are asked to
use the worksheet individually and quietly to (a) name the
Debriefing using DML is best accomplished away from the patient, (b) note the first thing that comes to mind about
simulation or direct care setting in a comfortable and the clinical encounter, (c) list what went right, (d) list
private environment to foster student learning. Two pre- what did not go well or could have been done differently,
mises of this method are: (a) the patient or client has a and (e) describe the patient’s story to set the frame. These
name and a story that is detailed and descriptive and (b) reflections-on-action (Sch€on, 1983) are written on the
debriefing is a form of clinical teaching; therefore, an worksheet as individual and personal notes that will be
educator with clinical knowledge of the care of the used later to inform the discussion as well as to unload
particular patient population is essential. Although many and park the emotions students may be feeling
debriefing methods use an open or facilitated discussion (Figure 2). Simulation and other clinical experiences
approach, or even encourage participants to debrief them- can foster many different emotional responses in students.
selves, DML uses a consistent structure with a clinical Although emotions can foster learning, they can also
teacher as facilitator each time prelicensure students are obstruct it and usurp debriefing time away from discus-
debriefed to teach the process of clinical reasoning sing the patient care that was provided or the decisions

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Figure 2 Sample from DML Worksheet Page 1. Available at: Dreifuerst, K.T. (2010). Debriefing for meaningful learning: Fostering
development of clinical reasoning through simulation. (Order No. 3617512, Indiana University). ProQuest Dissertations and Theses,
212. Retrieved from http://search.proquest.com/docview/1527174151?accountid=7398. (1527174151).

that were made (Shinnick et al., 2011). The process of un- simulation environment although the same process would
loading and parking emotions onto the worksheet not only be used in other clinical experiences.
acknowledges the presence of an emotional response but As the simulation involving an 80-year-old woman with
also facilitates a transition to active discussion and reflec- acute respiratory distress is concluding after a multistep
tion through the debriefing method. assessment process and interventions including administra-
Although students begin by listing what went right and tion of oxygen and medications by the students, the patient
wrong on the worksheet, in DML, these are not specifically speaks through slowly resolving, labored, shallow breaths
discussed in the group unless they are revealed in the and asks those caring for her if there is not anything
explore or explain phases of the DML debriefing process. more they can think of to help her breathe better. The stu-
Many debriefing strategies use what went right, what went dent in the primary nurse role bends close to the manikin
wrong, and what would you do differently as the primary and says, ‘‘We are here and taking good care of you. We
cues for discussion, a tradition that goes back to military called the doctor and have implemented all the orders.’’
and airline debriefing (Fanning & Gaba, 2007; Rudolph, When she leans down, she brushes against the patient,
Simon, Rivard, Dufresne, & Raemer, 2007). DML, howev- and the nasal cannula with oxygen comes off. She attempts
er, focuses on the patient situation as the frame and then to replace it, and the wig and glasses the patient is wearing
moves to discussing the actions and thinking of the students go askance. It is the fifth time in the simulation that the
within the clinical context, without judgment, to unpeel and nasal cannula has had to be replaced. The previous four
reveal students’ thinking behind their actions. times, the patient has removed it in her anxious state.
After the students have had several minutes to complete Like the other times, the pulse oximetry alarm sounds as
the first four boxes on the first page of the worksheet the patient’s PO2 plummets. The student nurse begins a ner-
(Figure 2), the clinical teacher begins the group reflection vous giggle and turns to a peer. As she turns, she knocks the
by facilitating a discussion about the patient’s story, frames IV pole down to the floor with a loud clang, and the room
the clinical issues and nursing priorities, and engages stu- erupts with contagious laughter. The simulation ends, and
dent interaction through Socratic questioning. The example the students begin loudly chatting about the wig and the
that follows in italics demonstrates its actual use in a cannula with increasingly boisterous laughter. They get to

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Figure 3 Sample from DML Worksheet Page 2. Aavailable at: Dreifuerst, K.T. (2010). Debriefing for meaningful learning: Fostering
development of clinical reasoning through simulation. (Order No. 3617512, Indiana University). ProQuest Dissertations and Theses,
212. Retrieved from http://search.proquest.com/docview/1527174151?accountid=7398. (1527174151).

the debriefing room, and the conversation is no longer nurses, interdisciplinary practitioners, family members, or
about the patient. As the teacher enters, the students are observers. With the faculty acting as guide and prompt,
verbally reminded that the first step of debriefing is to they continue going through pertinent assessments, find-
take a DML worksheet and independently complete the sec- ings, decisions, actions, and responses that occurred during
tions about the patient’s name, story, what went right, what the simulation experience. Clinical teachers guide students
went wrong, and the first thing that comes to mind as they through the processes of thinking-in-action and thinking-
reflect on the clinical experience. With one last laugh, a stu- on-action, making each evident within the clinical experi-
dent asks aloud if the patient even had a name, but another ence. Recordings of the simulation may be used during this
who has begun completing the worksheet sections on what phase as examples or exemplars. During the explore phase
went right and wrong is now refocused, reminds her they of DML, students and teacher use the worksheet and
have been caring for Mrs. Martha Webber who was whiteboard to (a) list or conceptually map the care of the
admitted from the assisted living facility yesterday with patient including identifying the central issue, diagnosis, or
pneumonia, and with a sigh adds quietly ‘‘. and we didn’t area of concern (DML worksheets offer both a list option
do such a great job of it either.’’ The others are now en- and a concept mapping option as some teachers and
grossed in the initial sections of the worksheet, and the students prefer a more linear record and others a more
room gets quiet. In a couple of minutes, the teacher is ready conceptual diagram), (b) note the relationships between
to begin the debriefing discussion with students who are assessments, findings, decisions, actions, and responses,
focused and ready to participate. and (c) link the relationships to what is known about the
patient (frame), what is expected, and what is unexpected
Explore (Figure 3).
The focus of the teacher’s Socratic questioning during
In the explore phase of DML, the students first recall in this phase of debriefing is to uncover students’ thinking. As
discussion the patient’s story and the focused issue(s) for the relationships between findings, decisions, and actions
the nurse to consider. Together, they review the clinical are uncovered, it is common to find both correct and
experience from the perspective of the roles they had: incorrect assumptions and knowledge application (Macchi

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& Bagassi, 2014). Teachers are encouraged to challenge and actively discussed in the context of thinking like a
taken-for-granted assumptions the students have, whether nurse. These interactions develop reasoning skills. It is
they are correct or incorrect, because some students choose during this phase that errors are corrected and incorrect
and demonstrate the correct nursing action but have incor- steps in assessment, interpretation, decisions, and actions
rect reasoning. Other students may choose and demonstrate are identified and rectified. Teachers are often surprised to
incorrect nursing actions but have correct reasoning for do- discover that students’ thinking falls into all four quadrants
ing so. Without deep discussion, the teacher and students of assumptions (Figure 1).
may never identify these inconsistencies between actions Again, Socratic questioning guides this process in a
and reasoning. The use of the DML explore phase makes nonthreatening manner that facilitates learning. ‘‘What-if’’
visible mismatches in reasoning, actions, and decisions and ‘‘tell me more’’ questions are common in this phase of
and provides the foundation for guided discussion to correct DML debriefing. During the explain phase of DML,
the inconsistencies and prepare for the extend phase of students and teacher use either the second (linear) or third
DML as the debriefing concludes. The explore phase of (conceptual) pages of the worksheets and a whiteboard to
DML helps teachers uncover student’s ability to hypothe- (a) review the clinical experience from the perspective of
size, generalize, synthesize, infer, and apply nursing knowl- all the participants, (b) return to the initial what went right
edge contextually and determine what they really know and and what went wrong notes that the student and teacher
do not know. This critical phase can prevent future clinical made when debriefing began, (c) add details about assess-
errors by identifying and correcting them before they occur. ments, findings, decisions, actions, and responses, and (d)
While they are discussing the decision the student made identify and correct the errors and make the impact of the
during the simulation to apply 2 L of oxygen by nasal can- corrections evident on the overall care of the patient.
nula to the patient having respiratory distress, the teacher ‘‘I disagree,’’ says a student who was an observer of this
asks him, ‘‘What in your assessment helped you to make simulation experience. ‘‘I remember the discussion about
that decision?’’ He replies that he noted the patient had res- my patient Mr. Anderson and all the blue ink around mak-
piratory distress at rest. The teacher then asks how supple- ing choices for O2 delivery.’’ Several heads nod but others
mental oxygen will help the patient, and he says, ‘‘It will shake their head and agree with the student acting as the
increase the amount of O2 the patient inhales.’’ After a brief primary nurse. ‘‘How will we figure this out’’ asks the clin-
discussion about oxygenation with several points of clarifi- ical teacher. A student on the other side of the room agrees
cation, she follows up by asking why he chose to use 2 L of to look it up and shares the information she finds. For 10 mi-
oxygen delivered by nasal cannula, and he responds, nutes, the students and teacher discuss supplemental oxy-
‘‘Since the patient was breathing quickly she was exhaling gen delivery options, including the benefits and
too much CO2 and to balance that, I knew I would only be indications of the various equipment choices and amount
safe giving her 2 L of supplemental oxygen and that could of oxygen delivered by each, as well as reviewing again
only be done with a nasal cannula.’’ The teacher asked how how supplemental oxygen impacts acute respiratory
he knew that, and he states that all the patients he had distress and pneumonia. The assessment findings,
cared for thus far who were older and required oxygen decision-making criteria, and patient outcomes are
like this. They all received 2 L and only by nasal cannula included in this phase of debriefing as the teacher uses a
so that must be the standard of care. The teacher writes combination of Socratic questions (how, why, when) with
down his comments in black marker on the whiteboard, all the students who participated in or observed the experi-
but puts a small asterisk by them to ensure the discussion ence and also provides information to correct misconcep-
will return to clarify this misconception. Meanwhile, tions and knowledge. Although guiding the debriefing, the
some students in the room agreed and others disagreed clinical teacher is also making notes in various colors on
aloud. The debriefing moves to the explain phase of DML. the whiteboard to represent the discussion. Because the
clinical instructor is also concerned about one of the medi-
Explain cation choices and curious about how the students inter-
preted some of the physician orders they received during
The explain phase of DML is an interactive process the scenario, those are also discussed in detail using this
between the student and teacher. Each is articulating the same iterative process.
thinking processes that underpinned patient care. These
include assessments, assumptions, interpretations, deci- Elaborate
sions, actions, and outcomes. During this phase of debrief-
ing, questioning and responding takes on new meaning as Although debriefing is not a time to lecture or introduce
the teacher is uncovering the thinking behind the actions new knowledge or ideas, it can be an opportunity to
and helping students to learn to challenge taken-for-granted emphasize the nursing knowledge, skills, and attitudes
assumptions. Thinking processes including deduction, in- that were evident in the clinical experience or simulation
duction, analysis, and inference are showcased, modeled, and explain missing pieces (Decker et al., 2013). Clinical

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care is a complex intersection of observations, decisions, evident and the better choices apparent. Although the entire
actions, and interactions that synthesizes knowledge and debriefing represents reflection-on-action, this careful
demonstrates thinking like a nurse. Elaborating on specific attention to the critical points in the experience helps stu-
ideas, concepts, knowledge, behaviors, and components of dents learn moments of reflection-in-action to be aware of
the clinical experience can expand analytic and inferential going forward.
thinking. During the elaborate phase of DML, students During the debriefing discussion, the teacher guides the
and teachers use the worksheet and whiteboard to (a) high- students to review several key areas that did not go well
light strengths the students demonstrated, (b) emphasize with the simulation by starting with principles of oxygen
links in nursing knowledge and application, and (c) discuss supplementation and ending with the patient outcome of
concepts of interest in greater depth. unresolved respiratory distress. During this phase, the
As the DML explain phase regarding supplemental oxy- clinical instructor walked the students back through all
gen is winding down, the teacher recognizes that the stu- the assessments, interpretations, decisions, and actions
dents are becoming deflated about their experience. She that occurreddnoting them on the whiteboard and again
turns to the student on her right who has just stated, ‘‘I highlighting with different colored markers. The clinical
can’t believe that even though we put oxygen on our pa- instructor finishes this phase of debriefing by highlighting
tient, we didn’t even really get that part right.’’ The teacher the change item marked in blue one more time.
then refocuses the debriefing on the elaborate phase by
asking everyone to share one thing they thought went Extend
well during the simulation and why. Another student men-
tions that the patient was breathing easier. Other students Finally, debriefing concludes by extending what was
name several things that were unrelated to oxygenation learned from this clinical experience to the next that the
but important to the care of this patient given her clinical student will encounter through guided anticipation and
situation, and the teacher acknowledges those she agrees active assimilation or accommodation. To do this success-
with and questions those she does not by asking students fully, the teacher follows the wrap up of the evaluate phase
to share their thinking and decision making. Throughout by challenging students to think-beyond-action (Dreifuerst,
the debriefing, the teacher is noting things that students 2009). This ability to anticipate or consider the ‘‘what if’’
say in black marker on the whiteboard, things that were distinguishes the novice nurse from the expert nurse and
correct are highlighted with green marker, things that represents higher order thinking and clinical reasoning
were wrong or need change in red marker, and changes dis- based on metacognition (Pesut, 2004; Tanner, 2006).
cussed in blue marker. The elaboration and discussion are Assimilation and accommodation can be modeled or facil-
upbeat and affirming. itated during debriefing using techniques such as Socratic
dialog, where students explicate thinking and actions and
Evaluate faculty guide the reflective process using provocative or
directed questions, laying the framework for thinking-
During this phase of DML, the students and teacher judge beyond-action through purposeful discourse. The use of
the clinical experience or simulation and determine what ‘‘what if’’ questions, in which the details and frame of
did not go well. This phase, similar to the other phases, is the clinical situation are changed, encourage the student
iterative and often occurs simultaneously with the other to think beyond the boundaries of one situation and antici-
phases. Using Socratic questioning, the teacher first has pate the next, modeling anticipatory reflection. To do this,
students explain their thinking and then takes them into the the teacher asks the students to consider a parallel case in
process of reflection-on-action (Sch€ on, 1983) by guiding which the clinical frame is different. Students need to deter-
them to reflect on the clinical situation, their assessment, mine what would be the same in this new frame and what
interpretation, decisions, actions, and outcomes. When would be different. This process of having a student
possible, identification of the error in judgment by the stu- actively think-beyond-action and anticipate decision mak-
dent, a peer, or the teacher can be important for learning ing needed when encountering a different yet conceptually
from the experience. The evaluate phase concludes with a similar clinical situation also teaches inferential and ana-
quick review of all the things that went well and those lytic thinking. During the extend phase of DML, students
that did not, and how they should have been done during and teachers use the worksheet and whiteboard to make
the clinical experience by highlighting the green and blue evident crucial points of thinking-in-action, thinking-on-ac-
ideas on the whiteboard and worksheets. This last step is tion, and thinking-beyond-action that occurred during the
critical for framing the experience in a meaningful way clinical experience.
for the next clinical situation that is encountered. By setting During the conclusion of debriefing, the teacher reminds
the experience in their memory with the decisions, actions, students that this simulation involved an 80-year-old
and responses now corrected, the next time they need this woman with several comorbidities who was admitted with
knowledge, it can be recalled with the miss-steps clearly pneumonia. She asks them to consider what would be

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similar and what would be different if their patient was a Dreifuerst, K. T. (2012). Using debriefing for meaningful learning to foster
12-year-old boy with a history of cystic fibrosis who was development of clinical reasoning in simulation. Journal of Nursing Educa-
tion, 51(6), 326-333. http://dx.doi.org/10.3928/01484834-20120409-02.
admitted with pneumonia. Because there is no time to Dreifuerst, K. T. (2010). Debriefing for meaningful learning: Fostering
discuss this as a group, the students are asked to write development of clinical reasoning through simulation. (Order No.
this up as a part of their clinical assignment which will 3617512, Indiana University). ProQuest Dissertations and Theses, 212.
be due the next time they meet. The teacher reminds stu- Retrieved from http://search.proquest.com/docview/1527174151?
dents that on hearing report on their patient, nurses accountid¼7398 (1527174151).
Dreifuerst, K. T. (2009). The essentials of debriefing in simulation learning:
actively begin to reflect-on-action as they anticipate what A concept analysis. Nursing Education Perspectives, 30(2), 109-114.
they will encounter as they leave report and approach the Facione, N. C., & Facione, P. A. (2006). The health sciences reasoning
room, and this is part of thinking like a nurse. Moreover, test. Millbrae, CA: The California Academic Press.
they base their actions and decisions on how well the real- Fanning, R. M., & Gaba, D. M. (2007). The role of debriefing in
ity fits with what was anticipated in their interaction with simulation-based learning. Simulation in Healthcare, 2(2), 115-125.
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the patient and how much they need to change their Hayden, J., Smiley, R., Alexander, M. A., Kardong-Edgren, S., &
thinking based on the new set of clinical circumstances. Jeffries, P. (2014). The NCSBN National Simulation Study: A longitu-
dinal, randomized, controlled study replacing clinical hours with
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pp 268-275
Clinical Simulation in Nursing
Volume 11
Issue 5