The Difficulty of Transfer
Although transfer would seem to be a simple concept, demonstrating any amount of transfer has proved difficult. Research has not demonstrated the existence of general problem-solving abilities that could help in all situations,27 a finding labeled “content specificity” in medicine.28,29 Although it may not be surprising that transfer is not expected to occur between vastly different problems, even near transfer proved elusive in medicine, but also in mathematics, chess, physics,23,25 and computer programming.30 In the 1980s, Gick and Holyoak31 undertook a research program on analogical transfer, using Duncker’s32 radiation problem, asking students to solve the following problem:
You are a physician treating a patient with a malignant tumor that can be destroyed using rays, if it receives enough radiation. However, such radiation levels would also destroy the healthy tissues on the ray’s path. Lower intensities would not harm the healthy tissues but would not destroy the tumor either. What procedure would allow destruction of the tumor, while sparing healthy tissues?
Pause here to try solving this problem…. The solution entails targeting the tumor with several rays of lower intensity originating from different directions, so that the total amount of radiation within the tumor reaches the critical threshold without affecting healthy tissues. In Gick and Holyoak’s31 study, the problem was solved unaided by only about 10% of students.
In their experiment, Gick and Holyoak31 also asked participants to read an analogous military problem. In this story, the tumor is replaced by a fortress that an army general wishes to capture. Several roads lead to the fortress, but they are mined so that any large enough body of soldiers would detonate the mines. The general then decides to divide the army into small groups, each converging toward the fortress from a different road and overwhelming the fortress’s defenses without detonating the mines. When participants were required to read this story prior to solving the cancer problem, only about 30% of participants found the appropriate solution to the latter. However, when the experimenters hinted to the participants that both problems are analogous, 75% of them were able to solve the radiation problem. Transfer did not occur spontaneously because most participants initially did not notice the similarities between the two problems, but did so only when the analogy was pointed out. These results are in no way unique.33 It is now a generally accepted fact that transfer does not occur spontaneously, particularly for novice learners, and must be fostered specifically.29,34–37
Several factors explain why transfer might not occur. The required skills or knowledge (including the procedural knowledge required to decide when to use a particular skill or knowledge) may not have been appropriately acquired.30 The learning task may not appropriately reproduce the target task; that is, functional task alignment between source and target tasks is inadequate.38,39 Learners may not be highly motivated—an essential prerequisite to learning.40–42 Newer research even suggests that stress and emotions can aid in learning.43–45 Conversely, learners may experience cognitive overload.46,47 These factors (and several others) require distinct interventions and solutions. However, given the focus of this article on debriefing, we will mainly cover the cognitive factors that underlie the role of context in transfer. First, as described above, the similarity between the source and target situations might not be recognized. Second, knowledge is inextricably linked to the context in which it develops.21,23,34
Transfer and Similarity
Research has shown that reasoning occurs, in no small part, through a process of unconsciously mapping the current situation to prior exemplars stored in long-term memory based on the salience of specific features, the nature of which is still not entirely elucidated.22,48–52 Studies on analogical transfer categorize these features into surface and deep features.37,53 Deep features (sometimes called structures or functional attributes)22,25,36,37,53 constitute the core of a task or situation and determine the rules used to solve it.54 In medicine, they are the attributes that determine the diagnostic category of the problem.29 Surface features are the perceptual or semantic features that superficially describe a situation. In medicine, patient description and presentation are often surface features.29
Transfer entails matching the current situation to an exemplar stored in long-term memory based on deep rather than superficial features. However, surface features are more salient cues, so the similarity between the current situation and the stored exemplar—defined as their sharing deep features—may not be recognized, especially by novices, if their surface features are different.25,37,53,55 This explains why most participants in the experimentation by Gick and Holyoak31 described above did not spontaneously transfer the solution of the military problem to that of the radiation problem: The problems shared deep features (the underlying rules for resolution) but not superficial features.
Transfer also fails when a situation is mapped to a dissimilar exemplar that shares only superficial features. This causes “negative transfer”—that is, using the wrong prior instance to solve a situation24,56—and can explain some diagnostic errors. One study provided family medicine residents with a first set of ECGs accompanied by a case description.57 The residents were then asked to identify a second set of ECGs in which nondiagnostic features of the case description, such as the patient’s occupation or hobbies, were changed. This led to a 50% decrease in diagnostic accuracy, showing the importance of superficial features in analogical reasoning.
To summarize this point, knowledge is linked to the specific exemplars stored in long-term memory. Transfer is the result of cognitive processes that map the mental representation of the current situation to prior exemplars or stored analogues based on deep features. It fails when that similarity is not recognized or when superficial features are used to instantiate an erroneous exemplar.
Transfer and Situated Cognition
More recently, the theory of situated cognition has argued that reasoning and cognition are contextualized and that knowledge is tied to a specific situation.34,58 This new paradigm moves away from the idea that reasoning is a cognitive process that occurs within one’s brain. It suggests that reasoning is a process created through the coupling between the human agent and the physical environment,26 mediated by perception.59
In situated cognition, context—the physical, social, and cultural environment and resources24,60—gives meaning to learning; that is, learning is also situated.24,34,58 For example, one study showed that Brazilian street urchins could not transfer their ability to solve mathematical problems presented in the natural work setting to the same problems presented in a more formal, school-like setting.61 According to the situated cognition theory, for skills and knowledge to be transferable, they cannot be acquired independent of their context of use.34
The Nature of Context
To reconcile both frameworks, we suggest that cognition and decision making are the products of the interaction between the human agent, the task, and the environment (including its social and cultural components). The interaction between the agent and the environment defines the professional situation (a professional role or function in a given setting), and the interaction between agent and task defines the problem situation (a complete, complex, and significant task).62 The problem situation and professional situation define the context. We thus take a very broad definition of context, which includes all the features of the problem situation (e.g., the nature of the patient’s disease) and the professional situation (e.g., the environment and physical setting; the human and material resources such as available equipment; the noncognitive constraints on decision making, such as perceptual limitations).63
Debriefing Strategies to Improve Transfer
To improve transfer, debriefing should be approached as part of a cognitive apprenticeship.58,64 Similar to apprenticeship in the workplace, cognitive apprenticeship aims to use authentic learning contexts to foster meaningful learning and transfer. The teacher guides the learner through deliberate and progressive learning strategies to develop knowledge that can be generalized.64,65 The teaching methods put forth by this approach include several strategies that facilitate transfer. Among these, articulation, reflection, and generalization and discrimination are directly linked to the learner66 and served as the basis for the CDR model of debriefing, which we discuss below.
Positioning the lived situation within its family of situations
To facilitate transfer, the debriefer should help the learners recognize the differences and similarities between the specific situation they were confronted with and new situations within their family of situations, defined as “a set of professional situations that share enough characteristics with the target setting and task to allow mobilization of abilities and macroabilities that are similar or identical, in similar conditions.”62 The comparison should include both superficial and deep features—that is, the semantic elements of the situation, the diagnostic category, and the links between features.25,29 Moreover, the distinctions between both types of features should be made clear to the learners.
The first step in this process is to contrast the features of the case with those of the prototypal case—that is, the usual presentation of a given situation. The next step is to compare the case with other cases belonging to the same family of situations, for which the specific management strategies can be generalized or adapted. Of course, the family of situations depends on the topic of interest and will be different if the latter pertains, for example, to clinical diagnosis or to team communication. Most important, the boundaries of the family of situations—that is, the related cases for which management strategies may be expected to fail—must be defined whenever possible. By contrasting and comparing the case as lived by the learners and its family of situations, including fringe situations, the learners will be able to infer generalizable knowledge, as well as discriminant knowledge that needs to be adapted when the situation changes. Alternatively, case comparison can include the identification of hypothetical what-if variations in the simulated case.54
Transfer must also occur from the simulated case to its real-life counterpart. Consequently, the context of the simulated case must be contrasted with that of real life. In particular, any aspect of simulation (a simulation “artifact”) that has a definitive impact on management or on the reasoning process may limit transfer to real life and should be highlighted. If, for example, simulation requires the transformation of medical equipment or the adaptation of a specific procedure, such differences should be highlighted in debriefing to avoid a potential negative transfer to real life.
Studies show that, for both novice and expert participants, explicit comparison between situations yields better transfer than simply analyzing the situations independently.35–37,54 By making explicit the differences and similarities (generalization/discrimination) between the simulated case and the same case with hypothetical variations, between the case and other cases within the family of situations, and between the case and real-life situations, the debriefer underlines the deep features of the situation, reducing the influence of superficial features in transfer.23 This strategy should be interwoven throughout debriefing and will initially be a guided process: As highlighted previously, it is very unlikely that learners will draw comparisons on their own. With time, it should encourage students to adopt on their own the metacognitive strategy (strategy about learning) of looking for comparison opportunities between cases.54
Because the context in which knowledge develops is an integral part of what is learned, the first step in discussing a topic in debriefing is to analyze the learners’ mental representation of the lived situation, including the context with its social and cultural aspects. It is not the actual similarity between situations that determines transfer but, rather, the perceptual similarity.23 More precisely, the perceived similarity or analogy between two situations—in the case of SBE, between the simulated situation and a genuine professional one—results from interactions between perceived features of the situation with prior knowledge and mental representation of the source situation, which can be, in turn, modified.25,54,63 That situated and dynamically generated representation further determines the cognitive processes, strategies, and knowledge that are mobilized by the learners in context. Exploring the internal representation of the situation is usually initiated by asking the learners to mentally place themselves in the lived situation and to verbalize their understanding of the situation and context. This process of contextualization should highlight any discrepancy between the learners’ internal model of the situation and the actual situation, providing a window into possible performance failures and an opportunity to correctly reencode the situation within long-term memory.55
Determining the mental representation of the learners is a foundation to analyze their cognitive processes because that representation serves as foundation (or rationale) for their actions.67–69 The wrong representation could lead to mistakes when the learners’ actions are rationally justified by their erroneous internal image of the situation.69 Once articulated, the learners’ knowledge and cognitive processes should be compared with those of peers and of the debriefer expert through reflection, in an effort to identify the “knowledge gap.”64 Several debriefing styles and techniques, such as advocacy (assertion or opinion) and inquiry (interrogation) used by the model of “debriefing with good judgment,”16 focus on the processes of articulation and reflection, but their discussion is beyond the scope of this article.
Once learners have reflected on their actions within the context of the case, skills and knowledge must be deliberately abstracted to prepare them for application in the context of a new situation.23,64,70 Decontextualization is a metacognitive process of extracting the specific rules, heuristics, and processes that come to bear on a situation.71
In debriefing, decontextualization takes place when the learners, guided by the debriefer, verbalize the general principles and problem-solving strategies that underlie the topic under discussion, without reference to the specific context of the case.23,30 It is initiated by questions such as “What should we usually do when …?” or “What do you know about …?” While decontextualization can involve generating new knowledge, it is a means of extracting the principles and knowledge that can be generalized from their specific context of use, in order to prime them for application in new situations. It should ideally focus on management strategies rather than on general knowledge regarding the topic under discussion.
Once general principles are extracted and decontextualized, they must be contextualized again because contextualized knowledge is more readily available than abstract knowledge.25 Recontextualization forces learners to consider new situations in which the acquired knowledge might prove useful.55 It increases the number of analogues that can be later invoked in new situations21,55 and fosters the link between the actions and the context in which they are useful.26
During recontextualization, the debriefer verbally leads the learners in applying the problem-solving strategies to new situations belonging to the same family of situations and to their real-life counterparts. The management strategies are modified and adapted to the new context as required, based on the differences between the lived situation and the target situations. This requires mobilizing the general and discriminant knowledge that position the lived situation within its family of situations and that distinguish the context from that of real life, as previously discussed.
The first question that recontextualization aims to answer is the hypothetical “what-if.”19 For example, if the topic under discussion is recognition of a pulmonary embolism, the question would be “How would you recognize pulmonary embolism if, instead of presenting the symptoms she did, the patient presented with the following complaints …?” If the topic relates to management of postoperative pain, the question could be “How would you adapt the analgesic strategies we discussed in a patient with renal failure?”
Recontextualization also aims to determine how knowledge and strategies discussed in the context of simulation can be applied in real life, with its own sets of limitations and constraints. Otherwise, the knowledge and strategies would be tied to their learning context and unlikely to be transferred to real life. In discussing the best methods to communicate within a team, for example, the debriefer should not end the debriefing session without exploring how the communication strategies discussed must be adapted once the learners go back to their clinical environment, in which several health care professionals do not have knowledge of those strategies.
An essential part of recontextualization rests on using the learners’ (and the debriefer’s) past experiences as a springboard to discuss how to adapt and apply the strategies under discussion to similar cases or to real life. This helps further cement the acquired knowledge by anchoring it on a foundation of prior, activated knowledge.72
The CDR Model of Debriefing
Once the emotions or reactions phase of debriefing is over,18–20,73 debriefing should proceed through consecutive cycles of contextualization, decontextualization, and recontextualization, each aimed at a specific topic (Figure 1). Depending on the complexity of a topic, a given cycle could be very short or take up a substantial part of the debriefing. We recognize that strict adherence to a cyclical model is not always necessary.63 For example, even though decontextualization is interested in the broad principles and recontextualization focuses on specific (and novel) situations, they cannot always be distinctly separated given the dynamic nature of feedback.70 Moreover, multiple recontextualizations are sometimes likely to be conducted during a single debriefing cycle.
Once a cycle has been completed, a summary of the points under discussion is conducted (if possible by the learners, rather than the debriefer), highlighting the management strategies and their adaptation in different contexts. A new topic can then be brought forth. Debriefing does not always proceed in such a systematic manner. It can—and in some cases should—proceed more organically, with topics intertwining depending on the identified knowledge or performance gaps. However, the general principles highlighted in this model should be adhered to because it is unlikely that any meaningful transfer can occur without them. Preliminary data seem to suggest that debriefing based on principles of transfer can be more effective than standard debriefing.74
Whereas the CDR model of debriefing is particularly adapted to the cognitive aspects of performance, debriefing should usually go beyond those aspects, to include emotions—which, in current debriefing practices, are often narrowly confined to an initial “reaction phase”18,20—learner motivation, and the social aspects of performance. Although the CDR model of debriefing could be used for such topics when their management strategies are clear and consensual, other models should certainly be explored. There is, however, a paucity of studies on feedback regarding the emotional and social aspects of performance.
Of course, even in the context of debriefing, the strategies we describe here are not sufficient for learning. We deliberately focused the discussion on the importance of context in learning and on strategies used to overcome the limitations that context puts on transfer. However, other factors also determine learning, such as emotional engagement and motivation. Learners should engage affect and motivation in problem-solving situations and during the learning experience as a whole.40–42 They should also be able to identify what they know and what they do not know: They must engage in cognitive and metacognitive strategies75,76 proved to be associated with higher learning outcomes. The role of the debriefer is to encourage those strategies that lead to effective learning and to foster appropriate conditions for learning.
In this article, we have discussed the reasons for difficulty of transfer—specifically, the fact that knowledge and skills are inextricably linked to the context in which they are acquired. We proposed two strategies to improve transfer during debriefing. First, the context of the lived situation must be explicated by comparing it with other situations from the same family, with the prototypical situation, and with its real-life counterpart. Second, the debriefer should encourage a deliberate strategy of contextualization, decontextualization, and recontextualization for each topic of interest.
The current debriefing approach should be but one piece of an overarching strategy of instructional design that takes into account the importance of context in learning. Context should be considered at all steps of instructional design, including when establishing learning outcomes through a competency-based approach62 and when designing simulation scenarios. In particular, contextualization does not only occur during simulation but, rather, should be an important process when designing other learning modalities, including nonexperiential methods.66
It was not our intent to provide a very prescriptive model. Debriefers are encouraged to adapt the CDR framework, but we argue that the importance of context should not be ignored. Importantly, we believe that, with the teachers’ guidance, the learners must develop not only the knowledge and skills required by the learning outcomes but also the metacognitive abilities to decontextualize and recontextualize, both in postsimulation debriefing as well as in their real-life clinical setting. As Perkins and Salomon23 stated, “Aside from how one teaches, one can help students develop skills of learning for transfer.” We hope this article can help start learners on that path.
Acknowledgments: The authors wish to thank Ms. Florence Parent for her input and helpful advice, especially as relates to enactivism, pragmatism, situated cognition, and the newer cognitive paradigms.
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