Teaching beyond the simulated context
Carmen Gomar MD, PhD, Juan Manuel Perdomo MD,
The aim of any teaching is to provide the learner with the knowledge, skills and competences for acting in real life, in other words achieving learning transfer. Learning transfer is defined as the application of the acquired knowledge to a new situation.
The impact of simulation as a teaching methodology, especially in health sciences, has been recognised for years. The potency of simulation with its essential part, the debriefing, in comparison with other teaching methods, is of such magnitude and arouses so much enthusiasm in educators and students, that efforts has been devoted to build and expand it but without an in-depth analysis of the learning obtained.The recent paper of Rivière E et al, “Debriefing for the Transfer of Learning: The Importance of Context”, recently published in the prestigious journal Academic Medicine1, propose and describe a debriefing style named CDR: contextualisation-descontextualisation–recontextualisation. CDR deliberately helps the learner to distinguish between superficial or contextual features of the simulation and the deep features, which are the cornerstone to adequately solve the simulated situation.
Rivière et al describe CDR debriefing and justify it on psychopedagogic research carried out on multiple and variable teaching fields. The CDR debriefing model rests on the evidence that the learner fails frequently in making analogies and this fact should be deliberately induced by the instructor. The psychopedagogy has demonstrated that the learned experience is stored in our brain linked to the context in which learning was developed. There are many interesting experiences that link learning with context, some of them are described in the article1. One simple and representative example of this is the study in which a group of divers was subjected to the learning of a pair of words in different contexts, under water and on land2. Interestingly,words learned underwater were more easily remembered than on land.
The CDR debriefing strategy applied to simulation-based learning advocates that after the initial phase of emotions and reactions that follows the simulation actions and precedes the reflection, a cyclic process of contextualisation-descontextualisation- recontextualisation is applied to each topic selected for discussion. The novelty of this debriefing structure in simulation resides in the processes of descontextualisation and recontextualisation, since contextualisation is used in all debriefings. In contextualisation, the learner’s mental representation of the experienced situation is explored including the important social and cultural aspects. This learner’s mental representation comes from his/her prior knowledge and experiences as well as the perception of the situation, and all these ingredients have built his/her cognitive process. In contextualisation the learner should perceive the similarity between the simulated situation and real life. The “knowledge gap, that is to say the possible discrepancies between the learner’s mental model of the simulated situation and the currently real situation are highlighted providing the opportunity to re-encode the situation within long term memory. Most debriefings, as well as feed-backs, finish at that point, and may be appropriate at graduate’s level,but in the CDR model descontextualisation is the next step
Descontextualisation is an active metacognitive process, deliberately induced by the debriefer, in which the learners extract and verbalise the specific rules, heuristics and processes that come to participate the situation. The learner should be guided to verbalise the general principles and strategies to solve the problem presented but withdrawing the specific context of the case. It aims to extract the principles and knowledge that can be generalised out of the specific context of the simulated situation in order to benefit the application in new situations.This produces an abstract knowledge that is less readily available in the memory than contextualised knowledge and for this reason it should be transferred again to context in order to facilitate future retrieval to solve real situations. For that, CDR model proposes the third part of the debriefing process, the recontextualisation.
Recontextualisation forces the learner to visualise the new situation in which the acquired knowledge would be useful and reinforces the link between the actions and the contexts in which they would be useful. During recontextualisation, the debriefer verbally leads the learners in applying solving strategies to new situations belonging to the same family of situations and to their real life counterparts. Past experiences from the learners and also of those of the debriefed should be used in recontextualising process.
The length of CDR debriefing will vary according to the complexity of the approached topic. Once the CDR cycle for a topic is finished, a summary of the points under discussion is conducted, if possible by the learners rather than the debriefer and thereafter a new topic is approached. Rivière et al recommend applying CDR structure with the required flexibility. It can be very simple at students’ and novel resident’s level or complex at the professional level but it is applicable to any training or teaching levels, even in the clinical setting for residents.
The field of cognitive processes, especially in adults, is extremely complex and the paper of Rivière et al helps us to understand how to apply them to the simulation based learning debriefing. Furthermore, the paper provides practical examples on how to carry out CDR debriefing after a clinical simulated experience and includes an enlightening graphic scheme of CDR cycle.
Descontextualisation and reconceptualisation requires clinical experience in the domains of the simulation sessions in addition to skills as a debriefer, and therefore clinical simulation training cannot be delegated to professional simulation instructors. Anaesthesiologists with teaching responsibilities and tasks should be trained in the use of simulation-based learning and adopt it as one of the most effective teaching tools for teaching and training. In addition, designing effective simulation learning requires a deep understanding of the complexity of learning transfer.
When reading the Rivière et al1 article one realises the complexity of learning transfer and the need to induce a cognitive content beyond the context to obtain the maximum and unique benefits from simulation-based- learning. When considering the complexity of learning transfer and the need to induce a cognitive content beyond the context if we want to obtain the maximum and unique benefits from simulation-based- learning, we think that simulation training cannot be delegated in simulation professional instructors. Descontextualisation and reconceptualisation requires clinical experience in the domains of the simulation sessions besides abilities as a debriefer. Therefore, anaesthesiologists with teaching responsibilities and tasks should adopt the simulation-based learning as one of the most effective teaching tools for teaching and training but, according to the paper of Rivière et al1, the importance of the context should not be ignored. The authors state that the learner must develop not only the knowledge and skills required by the specific learning outcome but also the metacognitive abilities to descontextualise and recontextualise both in postsimulation debriefing as well as in the real life clinical setting. The article is a real eye-opener in simulation in health sciences and many conceptscould be incorporated into practice enablinga more effective learning method.
- Rivière E, Jaffrelot M, Jouquan J, Chiniara G. Acad Med 2019;94:796-803
- Godden D, Baddeley A.. Br J Psychol 1975;66:325-31