とりあえずということで（いひひ）

1. Debriefing
When
Learning
Occurs

2. Debriefing
ふりかえり
あいかわらず
依然として
得体の知れないもの

3. Review Articles
The Role of Debriefing in Simulation-Based Learning
Ruth M. Fanning, Mb, MRCPI,
FFARCSI;
and David M. Gaba, MD
T he aim of this paper is to critically review what is felt to be
important about the role of debriefing in the field of simula-
when they can immediately apply what they have learned.3
Their attitudes towards any specific learning opportunity will
tion-based learning, how it has come about and developed vary and depend on factors such as their motivation for at-
over time, and the different styles or approaches that are used tending training, on whether it is voluntary or mandatory,
and how effective the process is. A recent systematic review of and whether participation is linked directly to recertification
high fidelity simulation literature identified feedback (in- or job retention. Traditional teaching methods based on lin-
cluding debriefing) as the most important feature of simula- ear communication models (ie, a teacher imparts facts to the
tion-based medical education.1 Despite this, there are sur- student in a unidirectional manner) are not particularly ef-
prisingly few papers in the peer-reviewed literature to fective in adult learning, and may be even less so in team-
illustrate how to debrief, how to teach or learn to debrief, oriented training exercises. The estimated half-life of profes-
what methods of debriefing exist and how effective they are at sional knowledge gained through such formal education may
achieving learning objectives and goals. be as little as 2 to 2.5 years.4 In the case of activities requiring
This review is by no means a systematic review of all the both formal knowledge and a core set of skills, such as Ad-
literature available on debriefing, and contains information vanced Cardiac Life Support, retention can be as little as 6 to
from both peer and nonpeer reviewed sources such as meet- 12 months.5,6
ing abstracts and presentations from within the medical field Much of the research in teaching adults indicates that
and other disciplines versed in the practice of debriefing such active “participation” is an important factor in increasing the
as military, psychology, and business. It also contains many effectiveness of learning in this population.7 In fact, in any
examples of what expert facilitators have learned over years of given curriculum, learning occurs not only by the formal
practice in the area. We feel this would be of interest to nov- curriculum per se but informally through personalized
ices in the field as an introduction to debriefing, and to ex- teaching methods (informal curricula), and even more so
perts to illustrate the gaps that currently exist, which might be through embedded cultures and structures within the orga-
addressed in further research within the medical simulation nization (hidden curricula).8
community and in collaborative ventures between other dis- Adults learn best when they are actively engaged in the
ciplines experienced in the art of debriefing. process, participate, play a role, and experience not only con-
crete events in a cognitive fashion, but also transactional
THE BACKGROUND OF SIMULATION-BASED events in an emotional fashion. The learner must make sense
of the events experienced in terms of their own world. The
LEARNING
combination of actively experiencing something, particularly
Generally, in simulation-based learning, we are dealing if it is accompanied by intense emotions, may result in long-
with educating the adult professional. Adult learning pro- lasting learning. This type of learning is best described as
vides many challenges not seen in the typical student popu- experiential learning: learning by doing, thinking about, and
lation. Adults arrive complete with a set of previous life ex-
periences and frames (“knowledge assumptions, feelings”),
ingrained personality traits, and relationship patterns, which
assimilation of lessons learned into everyday behaviors. Kolb
describes the experiential learning cycle as containing four Debriefingに関する総説
related parts: concrete experience, reflective observation, ab-
drive their actions.2 Adult learners become more self-di- stract conceptualization, and active experimentation.9 Gibbs
rected as they mature. They like their learning to be problem also describes four phases: planning for action, carrying out
centered and meaningful to their life situation, and learn best action, reflection on action, and relating what happens back
From the Department of Anesthesia, Stanford University, Stanford, CA.
to theory.10 Grant and Marsden similarly describe the expe-
riential learning process as having an experience, thinking Society
for
Simula9on
in
Healthcare
2007
The authors have indicated they have no conflict of interest to disclose. about the experience, identifying learning needs that would
Reprints: Ruth M. Fanning, Department of Anesthesia, Stanford improve future practice in the area, planning what learning to
University Medical School, 300 Pasteur Drive, Stanford, CA 90314 (e-mail:
ruthfanning@ireland.com). undertake, and applying the new learning in practice.11
Copyright © 2007 Society for Simulation in Healthcare Simulation training sessions, which are structured with
DOI: 10.1097/SIH.0b013e3180315539 specific learning objectives in mind, offer the opportunity to
Vol. 2, No. 2, Summer 2007 115

4. 私たちの学びにおいて
もっとも大きな要素はなにか

5. 経験学習
学習とは経験の変換によって
知識が形成される過程である
Kolb

6. Simulation
安全な状況下で
Experience
を提供する

7. 体験することが目的ではない
体験して学び取ることが目的

8. 経験学習
学習とは経験の変換によって
知識が形成される過程である
Kolb

9. Not
everyone
is
naturally
capable
of
analyzing,
making
sense,
and
assimila9ng
learning
experience
on
their
own,
par9cularly
those
included
in
Highly
dynamic
team
based
ac9vi9es.
すべての人が自らの学習経験を
分析したり意味付けしたりすることが
できるわけではない

10. そこでデブリーフィングが登場する….
Debriefing
represents
facilitated
or
guided
reflec9on
in
the
cycle
of
experien9al
learning
デブリーフィングとは経験学習サイクルの中で
ファシリテーション、もしくはガイドつきで
行われる「振り返り」である

11. THE
DEBRIEFING
PROCESS
Models
of
Debriefing
The
natural
order
of
human
processing
（普通のプロセスとして）
1)
to
experience
an
event（ある出来事を経験する）
2)
to
reflect
on
it（それを振り返る（内省する））
3)
to
discuss
it
with
others（他者と話し合う）
4)
learn
and
modify
behaviors
based
on
the
experience
（学習し、その経験に基づき行動変容をする。）
Reflec9on
aYer
learning
experience
might
occur
naturally,
but
it
is
likely
to
be
unsystema9c.
普通にしていれば学習経験のあとの振り返りは自然と生じるはずだが
でも、それはあまりシステマチックにはならないんですね、、、
システマチックに行える方法として、、、デブリーフィングが必要

12. Debriefing Process
Ini9al
phase
:
The
recollec9on
of
what
happened
and
discrip9on
of
what
par9cipant
did
in
their
own
words
(自分の言葉で何がおこったのか、何をしたのか説明）
Second
Phase
:
Described
as
iden9fying
the
ways
in
which
emo9on
was
involved either
individually
or
for
the
group
（どのように思ってどのように感じてそのようにしたかを説明）
Third
Phase
:
iden9fying
the
different
views
formed
by
each
par9cipant
and how
they
correlate
with
the
picture
as
a
whole;
generaliza9on
and
applica9on
of
the
experience,
during
which
par9cipants
a^empt
to
make
comparisons
with
real
life
events
（客観的に参加者それぞれの視点から考える。
実際の出来事と比較してみて一般化していく。）

13. 「ふりかえりの 3ステップ」
何を(what?)、
だから何/なぜ(so
what?)、
ゆえに何/どうする(now
what?)
という構造化を用いる

14. THE
DEBRIEFING
PROCESS
To
Debrief
or
Not?（デブリーフィングをするのかしないのか）
Typically
topics
that
at
benefit
from
debriefing(デブリーフィングが効果的なのは？）
1)
Team
training（チームワークトレーニング）
2)
Crew
resource
management（CRMスキルトレーニング）
3)
Mul9disciplinary
training（多職種トレーニング）
Teaching
technical
skills,such
as
intunba9on,
does
not
require
In-­‐depth
debriefing
or
reflec9ons
テクニカルスキルにおいてはあまり深いデブリーフィングは要求されない
Learning
objec9ves,
Target
popula9on,
and
modali9es
of
simula9on
will
drive
whether
a
debriefing
is
useful
or
not
学習目標、どのようなグループに行うか、シミュレーションの種類などによって
デブリーフィングが有効かそうでないかが分かれる

15. もしできなかったら
失敗したらどうしよう

16. THE
DEBRIEFING
PROCESS
Approach
to
Debriefing（デブリーフィングに際し考慮すべきこと）
Approximately
half
of
the
par9cipants
found
It
a
stressful
and
in9mida9ng
environment
fear
of
the
educator
and
their
peer’s
judgement
参加者の約半数が
教える側の人間や一緒に受講する人による
「自分に対する評価」をストレスに感じている

17. THE
DEBRIEFING
PROCESS
Approach
to
Debriefing（デブリーフィングに際し考慮すべきこと）
Facilitator
must
provide
a
‘suppor9ve
climate’
where
students
feel
valued,
respected,
And
free
to
learn
in
a
dignified
environment.
ファシリテーターは受講者が尊重され、
自由に学べるような
「支持的環境（SUPPORTIVE
CLIMATE）」を
作らなくてはならない

18. THE
DEBRIEFING
PROCESS
Approach
to
Debriefing（デブリーフィングに際し考慮すべきこと）
Par9cipants
need
to
be
able
to
‘share
their
experiences
in
a
frank,
open,
and
honest
manner’
受講者側もフランクに、オープンに、
正直に経験を共有することができるように

19. THE
DEBRIEFING
PROCESS
Role
of
the
Facilitator
in
the
Debriefing
Process
the
skill
of
facilitators
as
being
an
important
factor
in
the
learning
process
and
the
CREDIBILITY
OF
THE
COURSE
ファシリテーターのスキル
→学習のプロセスにおいての重要な要素
コースの信頼度にも関わってくる

20. THE
DEBRIEFING
PROCESS
Role
of
the
Facilitator
in
the
Debriefing
Process
UNLIKE
THE
TRADITIONAL
CLASSROOM
TEACHER,
facilitators
tend
to
posi9on
themselves
not
as
authori9es
or
Experts,
but
rather
as
COLEARNERS
伝統的な教師と異なり、
ファシリテーターは「ともに学ぶ人」という立場

21. THE
LEVEL
OF
FACILITATION
and
THE
INVOLVEMENT
IN
THE
DEBRIEFING
PROCESS
DEPEND
ON
A
VARIETY
OF
GENERIC
FACTORS
（いろいろな要素でファシリテーションの度合いはかわるのです）
1 The
objec9ve
of
the
experien9al
exercise（目的）
2 the
complexity
of
the
scenarios（シナリオの複雑さ）
3
the
experience
level
of
the
par9cipants
as
individuals
or
team（経験の差）
4 The
familiality
of
the
par9cipants
with
the
simula9on
environment（慣れ）
5
9me
available
for
session（時間）
6
The
role
of
simula9on
in
the
overroll
curriculum（シミュレーションの役割）
7
Indivisual
personali9es
and
rela9onships,
if
any,
between
par9cipants（個人の関係性）

22. Three
Levels
of
facilita9on
in
Debriefing
Process
High
Par9cipants
largely
debrief
themselves
（自分でdebriefingできるチームの場合）
Facilitators
gently
guide
the
discussion
only
when
necessary
（必要なときだけ介入）
High
level
faci.
Is
a
low
level
of
involvement
（ファシリテーション高い、介入度低い）
Fasilitator
as
catalyst
（ファシリテーターは触媒）
The
use
of
pauses
to
allow
thoughmul
responses
and
comment
（ちょいと待つ）
Open-­‐ended
ques9on,
and
phrases
rather
than
statements
of
fact
（決めつけるよりはオープンクエスチョン）
The
armul
use
of
silence
is
the
technic
to
draw
further
discussion
from
the
group
（沈黙をより深いディスカッションのために使用する）

23. Three
Levels
of
facilita9on
in
Debriefing
Process
intermediate
Increased
level
of
instructor
involvement
（より介入の度合いがあがる）
Individuals
and
teams
requires
help
to
analyze
in
deep
levels
but
are
capable
of
much
independent
discussion
（助けはいるがちょいと助けると勝手に進んで行く）
Rewording
and
Rephrasing
rather
than
giving
an
answers
（答えを与えるより言い方を変えて話してみる）

24. Three
Levels
of
facilita9on
in
Debriefing
Process
Low
An
intensive
level
of
instructor
involvement.（かなり集中的にインストが介入）
Teams
show
li^le
ini9a9ve
or
respond
only
superficially（表面的な反応でしかない）
Asking
many
Ques9ons
/
strongly
directs
the
nature
of
discussion（たくさん質問する）
Faciitators
needs
to
be
direc9ve
to
operate
a
stepwise
or
pa^ern
of
analysis
（かなり指導的に細かく分析が必要）
Ex)
answering
for
par9cipants（答える）
/
confirming
statements（確認する）
agreeing（承認する）
/reinforcing
thoughts
and
ideas（考えを強化する）
ac9ve
listening（能動的にきく）
/
nonverbal
encouragement
such
as
nodding,
leaning
forward,
and
focused
eye
contact（非言語的な承認勇気づけ）

25. THE
DEBRIEFING
PROCESS
The
Debriefing
Seong
Debriefing
oYen
take
place
in
a
room
separate
from
the
ac9ve
por9on
of
the
Simula9on
to
allow
diffusion
of
ten9on
and
to
provide
a
seong
conduc9ve
to
Reflec9on
(場所を変える テンションの開放など）
The
debriefing
room
should
be
comfortable
private,
and
a
rela9vely
in9mate
emvironment(ex
a
large
auditorium
would
typically
not
to
be
appropriate)
（居心地のよい場所 あまり広すぎない場所）

26. THE
DEBRIEFING
PROCESS
The
Debriefing
Seong
The
sea9ng
arrangement
may
vary
with
the
style
of
debriefing
and
the
degree
of
facilita9on
intended
Tradi9onal
teaching
aproach
:
the
facilitator
may
posi9on
himself
at
the
head
of
the
table
（伝統的な教え方ではテーブルのトップに偉い人が座る）
Per9cipant-­‐directed
debrief
:
the
facilitator
may
posi9on
himself
among
the
par9cipants
away
from
the
table
/
out
of
the
sight
/
outside
of
the
room
（部屋から出て行っていい！！）

27. THE
DEBRIEFING
PROCESS
The
Debriefing
Seong
Not
all
debriefings
are
held
aYer
the
sims
:
teaching
technical
skils
team
behaviors
are
seriously
flawed
‘
in
scenario
debriefing
’
（デブリーフィングは必ずしもシナリオの終わりにやらなくてもよい）

28. THE
DEBRIEFING
PROCESS
The
Effec9veness
of
Debriefing
Sessions
Elements
of
a
good
debrief
Elements
of
a
poor
debrief
The
use
of
open-­‐ended
ques9on
The
use
of
closed
ques9ons
（オープンクエスチョン） （クローズドクエスチョン）
Posi9ve
reinforcement
Cri9cism（批判的）
（前向きな強化）
Ridicule（侮辱的）
The
use
of
cogni9ve
aids
Concentra9ng
on
errors（エラーにだけ）
（認知的補助）
Concentra9ng
too
much
on
technical
points
The
good
use
of
audiovisual
（テクニカルなことにだけ）
capabili9es
Not
enough
on
CRM
skills
（視聴覚機材の使用）
（CRMスキルについて十分出ない）
Crea9ng
a
non-­‐threatnening atmosphere
Performed
poorly
could
harm
the
trainee

29. 最近思うこと

30. よりリアルに近づき過ぎて
シナリオに失敗したときに
受講生の心が深く傷ついてしまう可能性がある。

31. メンタリング

32. Shimaoka
Debriefing
Method 開発中
Vent
What
happened?
Analyze(What
you
have
done
well?)
Analyze(What
you
have
done
Wrong?)
What
is
the
problem?
And
Solu9ons?
Summarize
Encouragement