identify the impact of the experience, gain insights into what mattered to the participants throughout the simulation, and to establish a shared mental model of the events which occurred. a debate in the healthcare simulation community exists regarding the exploration of feelings in the descriptive phase. one camp believes that the descriptive phase should allow an opportunity for participants to “blow off steam,” and release any tension which may have accumulated during the simulation scenario in order for learners to continue the debrief and subsequent reflection without pent-up emotion. others believe that the “venting” phase is not necessary and may explicitly make this statement in their debriefing models, or simply omit any reference to emotions or feelings at all. analysis the second phase of debriefing is often referred to as “analysis,” "description," or "discovering". this is the phase in which the bulk of the time of debriefing is spent, with a focus on participant performance, rationales, & frames. it is meant to be a time of reflective practice on what actually occurred during the scenario, and the reasons why events unfolded as they did. the analysis phase uncovers the decision-making process behind observed actions. common questions posed, or statements made, by a facilitator during this phase include: “tell me about during the scenario.” “what went well? why?” “what made things challenging?” “why do you think that happened?” participant performance is a key component during the analysis phase. however, performance can often be a difficult topic to broach with participants, as criticism or constructive feedback often incur negative feelings. there exists a framework for questioning named “advocacy-inquiry,” or the “debriefing with good judgment” approach, which aims to reduce negative experiences in medical simulation debriefing. advocacy inquiry. the use of advocacy-inquiry (ai) questioning is highly encouraged by nearly all authors of debriefing models. advocacy-inquiry consists of pairing “an assertion, observation, or statement” (advocacy), together with a question (inquiry), in order to elicit the mental frameworks – or schema – of both the facilitator and the participants.: 53 in phrasing questions this way, participants are made aware of the facilitator's own point of view in relation to the question being posed. note that the use of ai is most encouraged when a facilitator has a judgment about something which was observed during the simulation scenario. using ai eliminates the tone of judgment as well as the “guess what i’m thinking” which can occur when asking questions. application the third and final phase of three-phase debriefing structures is most commonly referred to as “application," or "summary". participants are asked to move any newly acquired insights and/or knowledge gained throughout the simulation experience forward to their daily activities or thought processes. this includes learning which may have occurred during the previous phases in the debriefing process. common questions posed, or statements made, by a facilitator during this phase include: “what are you going to do differently in your practice tomorrow?” “what new insights have you gained?” “what one thing will you commit to doing differently after this?” note that the summary here is not always in terms of re-stating the major points which were visited throughout the simulation & debrief, but more so emphasize the greatest impact of learning. the summary may be done by either the facilitator or the participants – debriefing models differ in their suggestions. in the latter, the participants summarize what was of most value for them. a summary by the facilitator consists of re-stating key learning points which occurred throughout the debrief. multi-phase debriefing structure while all debriefing models include the phases of the three-part debriefing structure, there are several with additional phases. these additions either explicitly call out specific features which may be included in the three-part debriefing model, such as reviewing learning objectives, or provide additional process recommendations, such as immediately re-practicing any skills involved in the original simulation scenario. examples of multi-phase debriefing structures include the promoting excellence and reflective learning in simulation (pearls) framework, teamgains, and healthcare simulation after-action review (aar). learning objectives as with any other educational initiative, learning objectives are of paramount importance in simulation and debriefing. without learning objectives, simulations themselves and the subsequent debriefs are aimless, disorganized, and often dysfunctional. most debriefing models explicitly make mention of stating learning objectives. the exploration of learning objectives ought to answer at least two questions: what competencies – knowledge, skills, and/or attitudes – are to be learned, and what specifically should be learned about them? the method of debriefing chosen should align with learning objectives through evaluation of three points: performance domain – cognitive, technical, or behavioral; evidence for rationale – yes/no; and estimated length of time to address – short, moderate, or long. learning objectives may be predetermined and included in the development of a simulation scenario, or they may be emergent as the scenario unfolds. it can be challenging for the novice facilitator to adapt to emergent learning objectives, as the subsequent discussion may be purely exploratory in nature with no defined outcome. conversely, the discussion may lead to a specific area of expertise which neither the facilitator nor participants are familiar with. in such situations, the facilitator and participants must be flexible and move on to the next objective, and follow-up with the debriefing of the emergent outcome at a later time. environment the debriefing environment consists of two main features: the physical setting, as well as the psychological environment. physical setting when choosing a space in which to debrief, one must consider whether the scenario which unfolded was a complex case. complex cases usually involve heightened emotions, interdependent processes, and require more time spent debriefing. as such, it is recommended that these types of debriefings occur in a separate room from where the simulation scenario took place. this allows for a release of tension as participants move from one place to another and encounter new surroundings. note, however, that it is important to remind participants not to begin debriefing during the walk to the new room. the momentum of the simulation leads participants to begin debriefing with one another as soon the scenario has finished. however, in order to establish a shared mental model with all participants, debriefing must occur in a fashion whereby all participants can hear one another and have a chance to respond. this is difficult to accomplish while walking down a hallway, or in any disorganized fashion. the location of the debriefing is ideally somewhere comfortable and conducive to conversation and reflection, where chairs can be maneuvered and manipulated. it is recommended that, during the debriefing, the facilitator(s) and/or participants be seated in a circle. this is done so that everyone can see each other and increase group cohesion. furthermore, the use of a circle implies equality among the group, and decreases any sense of hierarchy which may be present. psychological environment establishing psychological safety and a safe learning environment is of utmost importance within both the simulation and the debriefing period. as simulation participants often find the experience stressful and intimidating, worried about judgment from their peers and facilitator(s), establishing safety must be done from the outset of the simulation event. note that psychological safety does not necessarily equate to comfort, but rather that participants “feel safe enough to embrace being uncomfortable…without the burden of feeling that they will be shamed, humiliated, or belittled”.: 340 it is recommended that establishing safety begin in the pre-brief phase by alerting participants to the “basic assumption.” the basic assumption, derived from the centre for medical simulation at harvard university (n.d.), is an agreed upon, predetermined mental model whereby everyone involved in the simulation & debrief believe that all participants are intelligent, well-trained, want to do their best, and are participating to learn and promote development. additionally, rudolph et al. (2014) have identified four principles to guide the formulation of a psychologically safe environment: communicate clear expectations establish a “fiction contract” attend to logistic details declare & enact a commitment to respecting learners & concern for their psychological safety included in these principles is the notion of confidentiality. explicitly reminding participants that their individual performance and debriefing reflections are not meant to be shared outside of the simulation event can help foster participation. confidentiality builds trust by increasing transparency and allowing participants to practice without fear. evidence & further study there exists a paucity of quantitative data regarding the effectiveness of debriefing in medical simulation, despite lederman's 1992 seminal model for the systematic assessment of debriefing. nearly every article reviewed had a cry for objective studies regarding the effectiveness of debriefing, whether it be comparing: the myriad options of conversational structures, debriefing models, or the comprehensive 5 w's of who – debriefer, what – content & methods, when – timing, where – environment, and why – theory. currently, there are critical limitations in the presentation of existing studies, a sparsity of research related to debriefing topics of importance, and debriefing characteristics are incompletely reported. recommendations for future debriefing studies include: duration of debriefing educator presence educator characteristics content of debriefing structure & method of debriefing timing of debriefing and/or: who: debriefer number & characteristics what: the purpose of the debrief, formative vs summative assessment, individual vs team debriefing, method of debriefing, content covered, mechanics, etc. when: duration, post-event vs during-event vs delayed, etc. where: in-situ, separate room, hospital, learning centre, etc. why: theoretical underpinning of the debriefing model chosen & rationale pico: population, intervention, comparator, outcome current research has found that simulation training with debriefing, when compared with no intervention, had favorable, statistically significant effects for nearly all outcomes: knowledge, process skill, time skills, product skills, behavior process, behavior time, and patient effects. when compared with other forms of instruction, simulation and debriefing showed small favorable effects for knowledge, time & process outcomes, and moderate effects for satisfaction. types of simulations used in medical schools and teaching hospitals there many different types of simulations that are used for training purposes. some of the most known are the use of mannequins (referred to by the simulation company meti as human patient simulators, or hps for short) and standardized patients. as seen in the chart titled "types of simulation used in medical education" retrieved from the aamc article, medical schools are leading the way when it comes to the use of standardized patients, but teaching hospitals and medical schools are close when it comes to full-scale mannequins and partial task trainers. medical simulation efficiency in education according to a study conducted by bjorn hoffman, to find the level of efficiency of simulation based medical training in a hi-tech health care setting, "simulation's ability to address skillful device handling as well as purposive aspects of technology provides a potential for effective and efficient learning." more positive information is found in the article entitled, "the role of medical simulation: an overview," by kevin kunkler. kunkler states that, "medical simulators can be useful tools in determining a physician's understanding and use of best practices, management of patient complications, appropriate use of instruments and tools, and overall competence in performing procedures." training the main purpose of medical simulation is to properly educate students in various fields through the use of high technology simulators. according to the institute of medicine, 44,000 to 98,000 deaths annually are recorded due primarily to medical mistakes during treatment. other statistics include: 225,000 deaths annually from medical error including 106,000 deaths due to "non-error adverse events of medications" 7,391 deaths resulted from medication errors if 44,000 to 98,000 deaths are the direct result of medical mistakes, and the cdc reported in 1999 that roughly 2.4 million people died in the united states, the medical mistakes estimate represents 1.8% to 4.0% of all deaths, respectively. a near 5% representation of deaths primarily related to medical mistakes is simply unacceptable in the world of medicine. anything that can assist in bringing this number down is highly recommended and medical simulation has proven to be the key assistant. the use of high-fidelity simulation for health professional education is strongly recommended by the who because it leads to greater acquisition, retention, and transfer of technical and non-technical skills. in addition to reducing error, simulation is commonly used in medical and nursing education to prepare health professionals to perform sensitive exams such as the breast or pelvic exam or to assist with breastfeeding.