Adaptation of the US Army’s After-Action Review for Simulation Debriefing in Healthcare : Simulation in Healthcare

Journal Logo

Special Article

Adaptation of the US Army’s After-Action Review for Simulation Debriefing in Healthcare

Sawyer, Taylor Lee DO, MEd; Deering, Shad MD

Author Information
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare 8(6):p 388-397, December 2013. | DOI: 10.1097/SIH.0b013e31829ac85c
  • Free


Summary Statement 

Postsimulation debriefing is a critical component of effective learning in simulation-based health care education. Numerous formats in which to conduct the debriefing have been proposed. In this report, we describe the adaptation the US Army’s After-Action Review (AAR) debriefing format for postsimulation debriefing in health care. The Army’s AAR format is based on sound educational theory and has been used with great success in the US Army and civilian organizations for decades. Debriefing using the health care simulation AAR process requires planning, preparation, and follow-up. Conducting a postsimulation debriefing using the health care simulation AAR debriefing format includes 7 sequential steps as follows: (1) define the rules of the debriefing, (2) explain the learning objectives of the simulation, (3) benchmark performance, (4) review what was supposed to happen during the simulation, (5) identify what actually happened, (6) examine why events occurred the way they did, and (7) formalize learning by reviewing with the group what went well, what did not go well and what they would do differently if faced with a similar situation in real life. We feel that the use of the health care simulation AAR debriefing format provides a structured and supported method to conduct an effective postsimulation debriefing, with a focus on the learning objectives and reliance on preidentified performance standards.

Postsimulation debriefing is a critical component of effective learning in simulation-based health care education.1–3 When done correctly, postsimulation debriefing facilitates learning through active reflection on performance during the simulation, aids in the identification of mental models that lead to behaviors, and provides an opportunity to revise flawed mental models for application in future experiences.4–11 The process of reflective observation, facilitated during postsimulation debriefing, is a key component of the experiential learning cycle.9,12 Facilitating the postsimulation debriefing session in a constructive manner, in an effort to close identified performance gaps, is at the foundation of postsimulation debriefing as a type of formative assessment.11

Given the importance of postsimulation debriefing in simulation-based health care education, it is not surprising that multiple formats for conducting the exercise have been proposed.11,13–20 These formats are founded on learning theory, with input from behavioral science, and were adapted from earlier models of facilitated debriefing.6,13,21,22 Some of the widely used debriefing formats have been used during thousands of debriefings, have been taught to hundreds of medical educators, and have been adopted by internationally recognized medical agencies, such as the American Heart Association.15–17 Despite the wide adoption and use of these methods, many simulation facilitators continue to have difficulty formatting a postsimulation debriefing and struggle with how to skillfully and purposively facilitate the debriefing discussion. Previous reviews have noted a lack of empiric evidence to suggest an optimal format for postsimulation debriefing and highlight the need for further investigation and research in this area.3,13

In this report, we describe our work to adapt the US Army’s After-Action Review (AAR)23 process and postsimulation debriefing format for use in simulation-based health care education. The AAR format is a method of postsimulation debriefing that has been used within the US Army for almost 4 decades.24 According to military experts, the application of the AAR format to postsimulation debriefings has been a key element to the US Army’s success, and the AAR method has been widely adopted outside the military by multiple commercial organizations, such as Shell Oil, Colgate-Palmolive, and Harley Davidson.25–27 We feel the adapted version of the Army’s AAR debriefing format described here provides a well-defined structure to the debriefing discussion and supports the debriefing by focusing the discussion on intended learning objectives with reliance on preidentified performance standards (ie, benchmarking).

To begin this report, we will review the basic concepts behind debriefing in simulation-based education. We will then outline our experience in adapting the Army’s AAR format to postsimulation debriefing in health care and provide an overview of the health care simulation AAR process and a detailed description of the health care simulation AAR debriefing format. Finally, we will compare the health care simulation AAR debriefing format with other commonly used formats for debriefing in simulation-based health care education and outline potential benefits and limitations in the use of the health care simulation AAR debriefing format.


According to Lederman,6 debriefing can be defined as a “process in which people who have had an experience are led through a purposive discussion on the experience.” The debriefing process provides an opportunity for participants in a simulation-based education experience to step back and reflect in a critical way on their performance during the simulation. Learning during a postsimulation debriefing entails 2 basic assumptions as follows: (1) the experience of the participants during the simulation has affected them in some meaningful way and (2) cognitive processing of the simulation experience (in the form of debriefing) is needed to provide insight and maximize the learning impact.6 Without the reflection provided during the debriefing session, the experience of the simulation may remain just an experience and not be translated into learning.12

Key aspects of a successful postsimulation debriefing include creating a collegial atmosphere, using open-ended questions, holding an honest discussion of management strategies, concentrating on a few key learning objectives, and identification of the underlying principles that lead to misconceptions/errors.13,28 The debriefing process has 7 essential structural elements: the participants, the simulation experience, the impact of the simulation, the recollection of the simulation, the mechanism of reporting (oral, written, questionnaire, etc), time to process the simulation experience, and the debriefing facilitator who guides the participants through the recollection, reporting, and processing.6

As the “guide,” the debriefing facilitator plays a pivotal role in directing the debriefing conversation and moving the participants through a purposive debriefing discussion.6 The degree of guidance the facilitator provides has been categorized by Dismukes and Smith as22 “high” when participants debrief themselves with little assistance, “intermediate” if increased facilitator involvement is needed, and “low” if the facilitator actively guides the participants through the debriefing stages. With the use of this classification scheme, a low level of facilitation implies that the facilitator’s involvement in guiding the debriefing is high, and conversely, a high level of facilitation implies that the facilitator’s guidance in the process is low. Most published formats for postsimulation debriefing in health care describe a high-to-intermediate level of facilitation, with the facilitator assisting to guide the discussion only when necessary and asking questions only as needed to highlight key learning topics.11,15–20

Inherent in many published formats for postsimulation debriefing in health care is an open and relatively unstructured format for the debriefing conversation, typically divided into 3 broad conceptual phases.15–17 While teaching simulation facilitator courses for the US Army Medical Department’s Central Simulation Committee29 using these popular methodologies, the authors found that many novice and some experienced debriefers had continual difficulty determining how to best structure the debriefing conversation. As a result, we received multiple requests for a more formally structured debriefing format, which would assist debriefers in skillfully and purposively facilitating the debriefing discussion. Thus, we began to search for alternative debriefing formats.


The historical roots of the debriefing process lie in the military, where the process developed as a way to objectively review what happened during a mission or training exercise.12 One of the best known debriefing formats in the military is the US Army’s AAR23 (Table 1). The AAR may be one of the oldest continuously used postsimulation debriefing formats, with initial reports dating back almost 40 years.24 In 1993, the Department of the Army published Training Circular (TC) 25-20, “A Leader’s Guide to After Action Reviews,” which provides the current format for the Army’s AAR process.23 TC 25-20 outlines the fundamental principles behind the AAR debriefing process and provides detailed instructions on how to conduct an AAR in the US Army. In TC 25-20, the AAR is described as a “professional discussion of an event, focused on performance standards, that enables soldiers to discover for themselves what happened, why it happened, and how to sustain strengths and improve weaknesses.”23 The behavioral science theories and principles that provide the foundation for the Army’s AAR have been extensively reviewed and include information feedback, performance measurement, memory and cognition, group performance and dynamics, communication theory and techniques, as well as instructional science.25

US Army AAR Format

The idea of adapting the Army’s AAR for debriefing in simulation-based health care education stems from the authors’ personal experiences with simulation-based training in the Army, including participation in predeployment training exercises at the National Training Center in Fort Irwin, California, where the AAR format was perfected.25 Based on our personal experience with the AAR method and the successful use of the technique within the military25 and civilian organizations,26,27 the authors became convinced that the AAR format could be successfully adapted to simulation debriefing in health care. In fact, it seemed prudent to the authors that the health care simulation community take advantage of the significant work devoted to the development of the Army’s AAR to best facilitate performance improvement during simulation-based health care education.

Because the AAR was originally designed to aid debriefing after combat training exercises, the format required some revision to be more applicable to debriefing in simulation-based health care education. Specifically, the 10 steps of the original Army AAR (Table 1) were shortened to 7 steps (Table 2), with the removal of steps deemed nonapplicable to health care and elimination of the military specific components. This adapted version of the AAR format for health care simulation is based on the authors’ understanding of the directions and intent of US Army TC 25-20 and our personal experiences using the health care simulation AAR format during multiple health care simulation debriefing sessions we have facilitated. The health care simulation AAR format of debriefing is currently taught as part of the Central Simulation Committee’s Faculty Development Course and has been taught in workshops at national and international meetings where it has been well recieved.29–31

Health Care Simulation AAR Format

The use of the health care simulation AAR format for postsimulation debriefing is based on the premise that each episode of health care simulation provides an opportunity for performance improvement and that achieving performance improvement is best realized by conducting a well-run, structured, and supported postsimulation debriefing. Adapting the Army’s AAR format to simulation debriefing in health care is based on the presumption that the same basic principles used to successfully debrief teams of soldiers after a combat simulation can also be used to successfully debrief teams of health care professionals after a medical simulation.


To carry out a successful postsimulation debriefing using the health care simulation AAR, there are 4 phases that must be considered: planning, preparation, conducting the debriefing, and follow-up.23 Each of these phases is important in ensuring optimal learning from the simulation debriefing experience.

Planning for the Debriefing

Given the importance of the debriefing process to learning in simulation-based education, it is vital that simulation educators invest time in planning how the debriefing will be conducted. Considerations should include identification of learning objectives and observable performance benchmarks, selection of the debriefing facilitator, allotting adequate time for the debriefing during the simulation session, determining the location of the debriefing, and identifying any training aids that may be required.23

The ultimate goal of simulation-based training is performance improvement; therefore, it is critical to define learning objectives for each simulation exercise and identify metrics and standards that define optimal performance. In the Army, these metrics are determined by applicable military and unit-based standard operating procedures. In medicine, the metrics may derive from national guidelines of care (Advanced Cardiac Life Support, Pediatric Advanced Life Support, Neonatal Resuscitation Program, etc), hospital-based care practices, or those developed independently by the simulation educator. An example would be a simulated cardiac arrest in which there is a clearly defined time benchmark in which to deliver defibrillation. By defining the learning objectives for the simulation scenario during the planning phase and identifying specific, observable, and easy-to-assess performance benchmarks to discuss during the debriefing, the ability to provide formative assessment during the debriefing is optimized.11 Creating an easy-to-use, valid, and reliable performance evaluation tool, based on the learning objectives and performance benchmarks, may further facilitate the debriefing.

Determining who will facilitate the debriefing should be done during the planning phase. According to Army guidelines, the facilitator should be a someone who is both knowledgeable about the tactics, techniques, and procedures involved in the scenario and capable of performing the tasks themselves.23 In a health care scenario focused on clinical skills, this would equate to a subject matter expert, typically an attending physician or senior nurse, with adequate clinical experience with the simulated pathology. In a health care scenario focused on interprofessional teamwork skills and communication, this could be either a clinical practitioner or a nonclinical expert in interprofessional teamwork and communication skills.

Allotting adequate time for the debriefing is critical to ensure that the debriefing will not be rushed or skipped all together. There is no standard time frame on how long the debriefing session should take. According to some experts, the length of the debriefing should be at least as long as the simulation itself.21 Reported durations in the health care simulation literature generally range from 20 to 30 minutes.3

The location of the debriefing should be predefined before the day of training. Debriefing can occur either in the same area as the simulation or in a separate room. Regardless of where the debriefing is held, efforts should be made to ensure that the debriefing location is comfortable and conducive to conversation, to include seats for the participants and facilitators and space for any needed training aids (video playback equipment, etc).

Preparing for the Debriefing

“Preparation is the key to the effective execution of any plan.”23 Preparing for the debriefing is critical to ensuring optimal learning during the simulation session. Before the day of the simulation and debriefing, the facilitators should review the simulation scenario, learning objectives, and performance benchmarks developed in the planning phase. Before the simulation, the facilitator can perform a presimulation briefing, during which the purpose of the simulation training and the process of the simulation and debriefing are explained to the participants.13 Alternatively, that discussion can be reserved for the debriefing session if outlining the learning objectives before the simulation would give away too much information on the case and the expected management.

During the simulation, the facilitator should make careful observations of the performance of the participants to define the strengths and weaknesses and to develop teaching points. Ideally, observations are recorded on a predeveloped observation/evaluation tool or checklist, which includes the learning objectives for the exercise and relevant performance benchmarks. Reviewing video of the simulation is used by many simulation educators to enhance the debriefing experience. If video will be used during the debriefing, a plan for its use should be defined ahead of time. Positive aspects of video review are its ability to provide objective evidence of performance and clear up disputes. However, the benefits of video review during debriefing on performance improvement in health care simulation have yet to be established.32–35

After the simulation and before the debriefing, the facilitator(s) should take a moment to organize their thoughts and observations. This is especially important when more than 1 facilitator is involved, to ensure that both have the same shared mental model for what transpired during the simulation and agree on the most relevant teaching points. Before starting the debriefing, any visual aids, including video equipment, should be readied and tested to ensure they work properly. During this period, the facilitator(s) may also wish to briefly review the steps of the health care simulation AAR, described later, and possibly rehearse what they will discuss.

Conducting the Debriefing

When conducting a debriefing using the health care simulation AAR format, the facilitator should use a high-to-intermediate level of facilitation22 to guide the participants through the stages of the debriefing. The 7 stages of the health care simulation AAR are completed in sequential order, which provides a standardized, structured, and supported format to the debriefing. This structured format avoids missing or jumping over important steps in the debriefing process. The 7 steps of the health care simulation AAR debriefing are summarized in Table 2. Key concepts to consider in each step are discussed later. An example script from a health care simulation AAR debriefing is provided in Appendix A.

1. Define the Rules of the Debriefing

Spending time introducing the rules of the debriefing upfront is a useful step in the debriefing process.6,11,12,15 This introduction phase sets the atmosphere of the debriefing and may have a significant impact on overall participation. This “predebriefing” period is the time during which an air of psychological safety should be established.12 The Army’s TC 25-20 encourages facilitators to describe the debriefing as a “dynamic, candid, professional discussion of training which focuses on unit performance against the standard.”23 Emphasizing that the debriefing is a discussion, not a lecture, helps to set the tone for the interactive conversation that should follow. In the introduction phase, all members of the team should be encouraged to participate. It should be clearly stated that the debriefing is not a critique and that no one has all the answers. Furthermore, it should be highlighted that the purpose of the debriefing is to maximize training benefits by allowing all participants to learn from each other. For participants who have extensive experience with debriefings, explaining all of the above in detail may be unnecessary. However, a brief introduction to the rules of the debriefing should always be conducted. If desired, defining the rules of the debriefing can be conducted before the simulation occurs.

2. Explain the Learning Objectives

Key to a successful postsimulation debriefing is a clear understanding of the desired learning objectives.28 As adult learners, simulation participants want to know what they need to know to perform optimally in their respective occupation.9,13 Failing to review the objectives of the training exercise may lead to confusion during the debriefing regarding, “what is this all about?” Such underlying confusion regarding the nature and intent of the training can easily distract participants from fully participating in the debriefing process. Making the learning objectives explicit and clear to all simulation participants will avoid ambiguity regarding the nature and importance of the training session and will increase buy-in and participation during the debriefing. It will also facilitate a shared mental model regarding the most critical aspects of the simulation and foster a focused discussion of these factors during the debriefing, potentially avoiding extraneous conversations on less important topics, thus maximizing the impact of training session. In some cases, it may be worthwhile for the facilitator to provide the learning objectives to the participants before the simulation, to allow the learners’ time to prepare. Alternatively, the identification of learning objectives can be pursued in an exploratory manner by the participants, via the facilitator posing a question such as, “what do you think the learning objectives of this simulation were?”

3. Benchmarks for Performance

A critical component to performance improvement is the identification of performance standards or benchmarks that define optimal performance.36 Without these benchmarks, it is impossible to identify performance gaps between the current level of performance and the desired level of performance.11 Using the health care simulation AAR format, relevant performance benchmarks should be explicitly shared with the participants during the debriefing. This critical step “opens the book” to the participants and further helps to foster an atmosphere of psychological safety by allowing the learners to know exactly what standards they are being held to. By knowing the benchmark for performance, the participants will be much more likely to achieve the standard during subsequent scenarios.

Ideally, the performance benchmarks will be integrated with the learning objectives for the simulation. For example, if the learning objective is to teach effective chest compressions, then the performance benchmarks should include specific metrics that define optimal compressions technique, for example, the use of a back board, proper compression depth, correct pace, and so on. To be useful, the performance benchmarks should be specific, observable, and easy to assess.11 According to the TC 25-20, 3 things need to be considered when determining performance benchmarks: the key tasks involved, the conditions under which each task is performed, and the acceptable standards for success.23

4. Review What Was Supposed to Happen

In the Army’s AAR, this step is referred to as the “commander’s intent” (Table 1). During this stage, the commander of the unit explains the mission and outlines what he/she intended to happen. In the health care simulation, this step involves a brief explanation of the simulation scenario, the expected actions, and their resultant impact on the scenario. For example, the facilitator could state, “What we intended to happen in this scenario was that the code team would enter the room to find a patient without a pulse, start chest compressions, identify a rhythm of ventricular fibrillation, and defibrillate the patient. After one shock the rhythm would convert to sinus.” Explaining what was supposed to happen facilitates a shared mental model of the intent of the training among the participants and further establishes a clear concept of what the simulation was all about and what the experience was designed to teach. Clarification of the intent of the simulation is especially helpful when the team strayed far afield of the intended course of the simulation. By stating explicitly what was supposed to happen during the scenario in the early phases of the debriefing, the facilitator encourages the participants to begin the process of self-reflection and an internal investigation of why the scenario did or did not play out the way the facilitator intended. When the simulation goes as expected, a review of the intended outcome is also helpful and can validate to the participants that they performed as expected with regard to the “big picture,” thus allowing them to focus on the finer points of their performance during the simulation.

5. Identify What Actually Happened

6. Examine Why Things Happened the Way They Did

Steps 5 and 6 occur simultaneously and comprise the bulk of the debriefing session. The discussion during these steps should comprise an open conversation aimed at recreating the events that transpired during the simulation exercise and an examination of why things happened the way they did. The use of open-ended questions and encouragement of the participants to discuss the important issues on their own with the lowest level of facilitator intervention possible should be practiced. It is within these 2 steps that the majority of the learning from the debriefing and the simulation session as a whole will occur.23 As this discussion is at the heart of the debriefing process, these 2 steps together should constitute roughly 50% of the total duration of the debriefing (Table 2).

During these steps of the debriefing, the facilitator should work to identify and fill any performance gaps among the participants. To accomplish this, the facilitator may need to function as a “cognitive detective” to discover the underlying mental models or “frames” of the participants, which caused them to act the way they did.11 By using conversational techniques such as pairing “advocacy” with “inquiry,”16 the facilitator can optimize reflective practice in the simulation participants, which is likely to result in meaningful change and improvements in performance in subsequent encounters.

These steps of the debriefing are critical if the postsimulation debriefing is to serve as a type of formative assessment or assessment for learning.11,37 As defined by Rudolph et al,11 formative assessment relies on learning objectives and performance benchmarks in several ways including providing a performance level against which actual performance can be compared, allowing for clear feedback regarding the gap in performance (below or above) to the desired level, and allowing facilitators to develop mini didactic lectures regarding the topic of interest. Thus, these 2 steps of the debriefing are intrinsically linked to the earlier steps in which the learning objectives and performance benchmarks were explicitly identified for the participants.

The progression through these steps of the debriefing can occur by 1 of 2 ways: chronological order of events or focusing on the key events/themes/issues.23 Either of these methods is appropriate, and each has benefits and drawbacks. The chronological review of events is logical, structured, and easy to understand. It allows participants in the simulation to mentally review the effects of their actions on the eventual results of the simulation (good or bad) and may allow both the participants and facilitator to better identify what actually happened during the simulation. A full recap of all the events of the simulation may, however, unnecessarily prolong the debriefing. Focusing the conversation on specific events or issues may speed the debriefing and optimize the learning by focusing in on the most critical components of the exercise. However, the facilitator must be careful to avoid the impression that the debriefing is a critique, especially in instances where there were multiple performance deficiencies. In those cases, the chronological review may lend a less accusatory tone to the debriefing by allowing participants to recall their performance during entire simulation (both good and bad), rather than just focusing on what went wrong.

7. Formalize Learning

In the final step of the health care simulation AAR debriefing, the facilitator helps the participants to summarize their performance during the simulation and formalize the lessons learned during the debriefing. In the theory of experiential learning by Kolb and Fry,38 this would correspond to the generalization stage, in which the facilitator helps the learners think critically and draw conclusions that might apply generally or theoretically to “real life.” Three questions the authors commonly used to facilitate this step of the debriefing are “what went well, what didn’t go well, and what would the team do differently next time if faced with this same situation in real life?”

Follow-up After the Debriefing

At the heart of performance improvement is the correction or remediation of errors as they are identified. Because the ultimate goal of the health care simulation is performance improvement, it is not appropriate to simply identify deficiencies or areas for improvement during the debriefing and then allow the participants to leave. Immediate repetition of the same simulation scenario, with repeated evaluation to determine if previous performance deficiencies have been corrected, is the most effective method to avoid this.23 The repetition serves 2 goals as follows: (1) it allows the facilitator to observe that previously identified performance deficiencies have been corrected and (2) it provides the students with a sense of accomplishment by having the chance to improve their performance and prove that they can perform to the standard. The concept of repetition until proficiency is achieved is encompassed in the concepts of deliberate practice and mastery learning.39,40 The utility of these practices in simulation-based education is well established.41–43


The majority of reports in the health care simulation literature outline a format for postsimulation debriefing that includes 3 broad conceptual phases. The 3 phases are described variously as, “gather,” “analyze,” and “summarize”17; “reactions,” “analysis,” and “summary”16; or “diffusing,” “discovering,” and “deepening.”15 The first phase is devoted to an investigation of the emotional impact of the simulation experience and an exploration of feelings or a recap of events. The second phase focuses on self-reflection and an investigation into the mental models that lead to the actions that occurred. The final phase involves a summary of what was learned during the simulation and debriefing. Fundamental in these debriefing models is an inherently open and relatively unstructured format within which the debriefing conversation unfolds. We have observed that the unstructured nature of these methodologies may make it difficult for many novice debriefers to skillfully and purposefully guide the debriefing conversation in an effective manner. We have seen that it also creates the potential for the conversation to stray away from the educator’s intended learning objectives for the simulation exercise.

In the authors’ opinion, the most significant advantages to using the health care simulation AAR format is the highly structured and supported framework it provides for the debriefing conversation and the focus it places on learning objectives and performance (Table 3). We feel the straightforward and relatively scripted progression of the health care simulation AAR debriefing, through 7 defined sequential steps, allows even novice facilitators to conduct a well-organized, concise, purposive, and productive debriefing. The potential for the health care simulation AAR format to expedite an effective debriefing is especially pertinent to busy health care professionals whose learning activities are under constant time pressure. Time spent early in the health care simulation AAR debriefing outlining learning objectives, defining performance benchmarks, and reviewing what was supposed to happen during the simulation ensures a shared mental model during the debriefing and helps to establish an atmosphere of psychological safety. It also allows participants to clearly understand the intended learning objectives of the training and provides an opportunity to objectively compare their performance against a known standard. We feel that the relatively rigid and semiscripted format and the explicit discussion of learning objectives and performance benchmarks set the health care simulation AAR format apart from other commonly used postsimulation debriefing methods in health care.

Potential Effects of Using the Health Care Simulation AAR for Postsimulation Debriefing

Clearly, there is no “one size fits all” postsimulation debriefing format, and the health care simulation AAR format is likely best suited for specific types of simulations. With its clear focus on performance improvement, based on a comparison of current performance with an established standard, the health care simulation AAR format is most appropriately used when performance standards for the simulation scenario are clearly defined and where the learning objectives are prespecified. It may not work well for simulations involving “emergent” learning objectives. Thus, the health care simulation AAR format does not work for every debriefing, but it does corresponds to accepted methods of good-quality debriefing in health care simulation as defined by Brett-Fleegler et al,44 wherein the facilitator takes time to set the stage for an engaging learning experience; maintains an engaging context for learning; debriefs in an organized way; provokes in-depth discussions, which leads to reflection on performance; and identifies what was done well or poorly and why to help participants improve or sustain good performance.

An obvious limitation of the health care simulation AAR format described here is the lack of empirical data to validate its use during health care simulation debriefing. In our experience, the health care simulation AAR format works well, and we have anecdotal reports of positive outcomes from people who have used it (Table 3). However, we do not have quantitative or qualitative data at this time. This lack of empiric data is not unique to the health care simulation AAR debriefing format. Like many aspects of debriefing, additional research is needed concerning the optimal format of the debriefing process.3 There is a general consensus regarding the importance of some sort of structure for the debriefing process, but what the optimal structure is remains to be determined.3,13,14 The optimal format of the debriefing likely varies based on the type of simulation training and the learning objectives for the session (technical skills vs. nontechnical skills, predefined vs. emergent objectives). Future research in this area should involve comparative investigations of different debriefing formats in different types of simulations to provide the simulation community with evidence on which to base decisions for choosing between the various debriefing formats.


In this report, we have examined the adaptation of the US Army’s AAR process to health care simulation debriefing and described the health care simulation AAR debriefing format. The Army’s AAR process is based on decades of research and experience and has been used with great success within the Army and the civilian business community. We believe the health care simulation AAR format we have described holds great potential to improve the state of debriefing in simulation-based health care education. Successful debriefing using the AAR process requires planning, preparation, and follow-up. We have defined the 7 sequential steps for conducting a debriefing using the health care simulation AAR format. We feel the health care simulation AAR format provides even novice debriefers with a well-structured and supported method to conduct a concise and productive debriefing, which focuses on learning objectives and performance benchmarks. Further research is needed to define the benefits of the health care simulation AAR format and its utility in health care simulation.


1. Issenberg SB, McGaghie WC, Petrusa ER, et al. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 2005; 27: 10–28.
2. McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research: 2003–2009. Med Educ 2010; 44: 50–63.
3. Raemer D, Anderson M, Cheng A, Fanning R, Nadkarni V, Salvoldelli G. Research regarding debriefing as part of the learning process. Simul Healthc 2011; 6: S52–S57.
4. Crookall D. Debriefing. Simul Games 1992; 23: 141–142.
5. Thatcher D. Promoting learning through games and simulations. Simul/Games Learn 1986; 16: 144–154.
6. Lederman L. Debriefing: toward a systematic assessment of theory and practice. Simul Gaming 1992; 23: 145–160.
7. Dewey J. Experience and Education. New York, NY; Macmillan; 1929.
8. Argyris C, Schon D. Theory in Practice: Increasing Professional Effectiveness. London, England: Jossey-Bass; 1974.
9. Kolb DA. Experiential Learning. Upper Saddle River, NJ: Prentice Hall; 1984.
10. Seel NM. Mental models and complex problem solving: instructional effects. In: Elen J, Clark RE, eds. Handling Complexity in Learning Environments: Theory and Research. New York, NY: Elsevier; 2006.
11. Rudolph J, Simon R, Ramer D, Eppich W. Debriefing as formative assessment: closing performance gaps in medical education. Acad Emerg Med 2008; 15: 1010–1016.
12. Pearson M, Smith D. Debriefing in experienced-based learning. Simul/Games Learn 1986; 16 (4): 155–172.
13. Fanning R, Gaba D. The role of debriefing in simulation-based learning. Simul Healthc 2007; 2 (2): 115–125.
14. Dismukes R, Gaba D, Howard S. So many roads: facilitated debriefing in healthcare. Simul Healthc 2006; 1: 23–25.
15. Zigmont JJ, Kappus LJ, Sudikoff SN. The 3D model of debriefing: defusing, discovering, and deepening. Semin Perinatol 2011; 35: 52–58.
16. Rudolph J, Simon R, Dufresne R, Raemer D. There’s no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simul Healthc 2006; 1 (1): 49–55.
17. Phrampus P. Debriefing in simulation education. Available at: Accessed February 11, 2012.
18. Van Heukelom J, Begaz T, Treat R. Comparison of postsimulation debriefing versus in-simulation debriefing in medical education. Simul Healthc 2010; 5 (2): 91–97.
19. Kuiper RA, Heinrich C, Matthias A, Graham M, Bell-Kotwall L. Debriefing with the OPT model of clinical reasoning during high fidelity patient simulation. Int J Nurs Educ Scholarsh 2008; 5 (1): 1–14.
20. Wallin CJ, Meurligh I, Hedren L, et al. Target-focused medical emergency team training using a human patient simulator: effects on behavior and attitude. Med Educ 2007; 41 (2): 173–180.
21. Steinwachs B. How to facilitate a debriefing. Simul Gaming 1992; 23 (2): 186–195.
22. Dismukes R, Smith F. Facilitation and Debriefing on Aviation Training and Operations. Aldershot, UK: Ashgate; 2000.
23. Training Circular 25-20, A Leaders’ Guide to the After-Action Review, Headquarters, Department of the Army, Washington DC. 30 September 1993. Available at:
24. Bosley JJ, Onoszko P, Kner C, Sulzen R. Tactical Engagement Simulation Training Techniques: Two Training Programs for the Conduct of After Action Review (ARI Research Product 79-2). Alexandria, VA: US Army research Institute for the Behavioral and Social Sciences. (AD A073 724); 1979.
25. Morrison J, Meliza L. Foundation of the After-Action Review Process. Special Report #42. US Army Research Institute for the Behavioral and Social Sciences; 1999.
26. Garvin D. A 2000 Guide to Putting Learning Organization to Work: The U.S. Army’s After-Action Reviews: Seizing the Chance to Learn. Boston, MA: Harvard Business School Press; 2000: 106–116.
27. Darling M, Parry C, Moore J. Learning in the Thick of It. Cambridge: Harvard Business Review; 2005: 84–92.
28. Manser R, Howard S. Key elements to debriefing for simulation training. Eur J Anaesth 2000; 17 (8): 526–517.
29. Deering S, Sawyer T, Mikita J, Maurer D, Roth B. The Central Simulation Committee (CSC): a model for centralization and standardization of simulation-based medical education in the U.S. Army healthcare system. Mil Med 2012; 177 (7): 829–835.
30. Sawyer T, Balog E, Eberly M, Warwick A. Debriefing After Medical Simulation Training. Workshop. Seattle, WA: American Academy of Pediatrics, Uniformed Services Pediatric Seminar; 2012.
31. Sawyer T, Halamek L. Post-simulation Debriefing Formats From the Army and NASA. Workshop. Orlando, FL: International Meeting for Simulation in Healthcare; 2013.
32. Savoldelli GL, Naik VN, Park JP, Joo HS, Chow R, Hamstra SJ. Value of debriefing during simulated crisis management. Anesthesiology 2006; 105: 279–285.
33. Byrne AJ, Sellen AJ, Jones JG, et al. Effect of videotape feedback on anaesthetists’ performance while managing a simulated anaesthetic crisis: a multicentre study. Anaesthesia 2002; 57 (2): 176–179.
34. Chronister C, Brown D. Comparison of simulation debriefing methods. Clin Simul Nurs 2012; 8 (7): e281–e288.
35. Sawyer T, Sierocka-Casteneda A, Chan D, Berg B, Lustik M, Thompson M. The effectiveness of video-assisted debriefing versus oral debriefing alone at improving neonatal resuscitation performance: a randomized trial. Simul Healthc 2012; 7 (4): 213–221.
36. Watson GH. Benchmarking Workbook: Adapting the Best Practices for Performance Improvement. London, England: Productivity Press; 1992.
37. Harlen W, James M. Assessment and learning: differences and relationships between formative and summative evaluation. Assess Educ Princ Pol Pract 1997; 4: 365–377.
38. Kolb D, Fry R. Toward an applied theory of experiential learning. In: Cooper C, ed. Theories of Group Processes. London, England: John Wiley & Sons; 1975.
39. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004; 79 (10): S70–S80.
40. McGaghie WC. Research opportunities in simulation-based medical education using deliberate practice. Acad Emerg Med 2008; 15: 995–1001.
41. Wayne DB, Butter J, Siddall VJ, et al. Mastery learning of advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate practice. J Gen Intern Med 2006; 21: 251–256.
42. Wayne DB, Barsuk JH, O’Leary K, et al. Mastery learning of thoracentesis skills by internal medicine residents using simulation technology and deliberate practice. J Hosp Med 2008; 3: 48–54.
43. Sawyer T, Sierocka-Casteneda A, Chan D, Berg B, Lustik M, Thompson M. Deliberate practice using simulation improves neonatal resuscitation performance. Simul Healthc 2011; 6 (6): 327–336.
44. Brett-Fleegler M, Rudolph J, Eppich W, et al. Debriefing assessment for simulation in healthcare: development and psychometric properties. Simul Healthc 2012; 7 (5): 288–294.



Healthcare simulation; Simulation debriefing; Facilitated debriefing; After-action review; Performance improvement

© 2013 by Lippincott Williams & Wilkins, Inc.