The making of expert clinicians: Reflective practice

Maestre, J.M.; Szyld, D.; del Moral, I.; Ortiz, G.; Rudolph, J.W.

doi:10.1016/j.rceng.2014.01.002

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Maestre, D. Szyld, I. del Moral, G. Ortiz, J.W. Rudolph" "autores" => array:5 [ 0 => array:4 [ "nombre" => "J.M." "apellidos" => "Maestre" "email" => array:1 [ 0 => "jmmaestre@hvvaldecilla.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "D." "apellidos" => "Szyld" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "I." "apellidos" => "del Moral" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "G." "apellidos" => "Ortiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "J.W." "apellidos" => "Rudolph" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Hospital Virtual Valdecilla, Servicio de Anestesiología y Reanimación, Hospital Valdecilla, Santander, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "New York Simulation Center for the Health Sciences, Emergency Medicine, New York University School of Medicine, Nueva York, United States" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Instituto de Simulación Médica, Cuidados Críticos, Hospital Santa Clara, Bogotá, Colombia" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Center for Medical Simulation, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, United States" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La formación de expertos clínicos: la práctica reflexiva" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 842 "Ancho" => 1564 "Tamanyo" => 59979 ] ] "descripcion" => array:1 [ "en" => "The relationship among mental models, activities and results. Mental models depend not only on the knowledge base but also on the rules, assumptions, goals and beliefs. These models consist of the images and stories that we have in our mind about ourselves, others, the institutions and all aspects of the world. The smaller arrow indicates the “single-loop learning”, which is based on correcting actions. The larger arrow indicates the “double-loop learning”, which is based on changing the mental models that give rise to the actions." ] ] ] "textoCompleto" => "IntroductionThe performance of healthcare professions requires continuous evolution.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> The exponential growth of new technologies, procedures and diagnostic and therapeutic strategies, the need to respond to countless productivity, efficiency and quality indicators at the individual and institutional level, the need to work in a team, the increasing presence of older patients and their associated diseases, as well as a transformation in the relationship between clinicians and patients and their families, among other factors, demand this constant evolution.Organizations that seek to provide quality care require expert clinicians, which is closely tied to the continuing development of their staff. Healthcare educators seek methods to help these professionals reach and maintain levels of mastery that are demanded by the complexity and continuously changing nature of modern health care.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Traditionally, training has been tied to the transmission of information in an organized and systematic manner by an outside expert, along with the repeated practice of medical procedures and skills.However, to benefit from the practice and reach their full potential, adults depend not only on the amount of practice but also on how it is performed. The theory of deliberate practice establishes a different approach and is defined as a type of highly structured practice that must meet certain requirements.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> We must interact with sufficient motivation, autonomy and without pressure to acquire expertise, approaches, behaviors and skills in practice areas of interest to the practitioner. To achieve the maximum benefit, our own abilities must be trained to the limit. The task should therefore represent a challenge and be well defined with extensively discussed and planned objectives and goals. Additionally, rigorous reflection on the performance is required. The participation of educators trained in teaching techniques that provide specific and constructive feedback is therefore essential.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>The training of teams using simulated cases studies, followed by reflection on the performance, has increased exponentially in the last decade as a teaching tool that adapts to the learning style of adult students.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> Simulated clinical cases help establish realistic and specific objectives without putting patients at risk, help students reflect on their performance in a structured manner and transfers the lessons learned to the daily work setting.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>In this article, we describe the relevant theories that give rise to reflective practice and the role of debriefing as a teaching technique to facilitate understanding of the reasons behind clinical performance.The development of the expert healthcare professionalWhile experience is the basis for adult learning, the Kolb theory of learning shows that this cannot occur without “rigorous reflection”. In other words, having experience is not necessarily the same as being an expert.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> “Rigorous reflection” is understood as a process that helps reveal and resolve clinical and behavioral dilemmas and areas of confusion that arise when dealing with a clinical case. Learning is a process that begins when facing a situation that is not fully resolved with the traditional resources. Individuals, motivated by a feeling of uncertainty and discomfort, seek to examine the experience: What was the nature of the problem? What were their intentions? What did they do? What happened? In the process of observation and analysis, there emerges the difference between intention and actual results. This stimulates and motivates the professional to seek out new responses and incorporate more effective strategies that, once conceptualized, can be used in similar future situations.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>“Reflective practice” is a term coined by Donald Schön who described it as the discipline of examining the values, assumptions and knowledge-base that guide professional practice.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> If this could theoretically occur in any situation and be conducted on an individual level then it is normally not a relaxed or meditative process. On the contrary, it is usually a demanding challenge that usually delivers a better result when performed collaboratively.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> Studies on perception and memory have shown that we are more conscious of the results of our thoughts than of the process that creates them. Rational explanations can omit the unconscious attitudes that generally guide the thought process, which hinders individuals in understanding what issues prevent them from improving.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>The conditions in which reflective practice is associated uniformly with improvements in performance include the presence of well-defined learning objectives, opportunities for deliberately practicing these objectives and reliable measurements for providing specific feedback, which enable gradual improvements in performance.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> In this context, the main aspect of the learning process is often identified as debriefing.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> According to the criteria of the Center for Medical Simulation of Boston, debriefing is defined as a conversation between two or more individuals who review a real or simulated event in which the participants analyze their actions and reflect on the role of their thinking process, psychomotor skills and emotional states to improve or maintain their performance in the future.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> Despite its importance, the practice of debriefing varies significantly among institutions and instructors. Thus, some institutions and instructors perform a rapid assessment of the performance and provide specific feedback, training (coaching) or direct teaching, while others create an environment where the participants can reflect and openly discuss.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> In some cases, the participants themselves perform the analysis without the presence of an instructor.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Current studies on the topic provide few guidelines on how to create an environment in which the professional feels both stimulated and psychologically safe to conduct a rigorous reflection after performing a clinical case. Consequently, there are various styles and approaches for practicing debriefing.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>The origin of debriefingSystematic learning constructed on experiences originated with the aviation industry of the 1970s, as a response to numerous crashes of aircraft flown by highly experienced pilots in the absence of technical failures. The aerospace authorities noticed that individual skills were not enough to ensure good flight outcomes. In the following years, first the U.S. Air Force and then NASA developed new methods to promote training in which an instructor “facilitates” a “debriefing” for the entire crew. This process critically analyzes the events that occurred during the flight and the performance of the team, even in cases that did not have fatal outcomes. This inclusion of analyses in daily practice contributed to a drastic decline in the number of aviation accidents and deaths.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>The U.S. Navy also initiated this learning approach to train personnel whose function was to face continuously changing conditions in a variety of circumstances. After subjecting soldiers to exercises for practicing missions, the Navy began performing “after action reviews”, a method for extracting lessons from an event or project and applying them to other situations.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>Based on these findings, numerous corporations, nonprofit institutions and government agencies reviewed the reasons why the methods for analyzing processes and projects commonly used to identify successes and failures had not penetrated the fabric of their organizations and become good practices and performance standards. They discovered that most strategies for disseminating the analysis of results consisted of various types of reports to their employees, such as documents and meetings, which did not facilitate the effective exchange of ideas, approaches and traditions shared by most people and that are transmitted from one generation to the next (the organization's culture). In contrast, aviation and the navy provided opportunities for learning to their members through feedback cycles between analysis and action.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>In 1999, healthcare institutions undertook a substantial change in the manner in which health professionals were trained. This was the result of a report by the American Institute of Medicine “To err is human”, which revealed that up to 94,000 people died every year in American hospitals due to medical errors. One of their recommendations was to develop and assess new approaches for improving training and reducing errors.<a class="elsevierStyleCrossRef" href="#bib0095">19</a>In the subsequent years and following these and other recommendations derived from various studies and organizations, a collaborative research project arose between the Center for Medical Simulation and the Harvard-MIT Division of Health Sciences and Technology (Boston, USA) to study the method for transferring lessons learned by other disciplines to the healthcare setting. As a result, a method was proposed to help healthcare professionals develop self-correction habits to replace behaviors that hinder reflection and changes following clinical practice. The professionals who learned to reflect in order to scrutinize their assumptions and mental routines were able to self-correct and improve their professional skills. Conversely, those without this ability tended to close up and ignore conflicting information, maintaining ineffective habits in their clinical practice.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>Reflective practice: methods and theoriesReflective practice is the systematic and continuous process of achieving the maximum benefit from experiences by learning from them.<a class="elsevierStyleCrossRefs" href="#bib0105">21,22</a> In the healthcare setting, there are various models for promoting this practice, such as the technical analysis of critical incidents, root-cause analysis and the use of mind maps. The central idea of the theoretical model analyzed in this study suggests that the clinical results observed are a direct consequence of the actions of individuals, and these actions in turn are the inevitable result of the thought processes with which the individuals interpret the condition, processes called “mental models”. Humans do not passively perceive an objective reality but rather perform a process to make sense of the experience, a process in which they actively filter, create and apply meaning to their environment. The theory that supports this approach comes from cognitive science, social psychology, psychology and anthropology.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> “Mental models” are deeply ingrained assumptions, generalizations and images that influence the way we understand the world and how we act. The terms for referring to these models are numerous and include cognitive framework, “reference framework” and “schedules”. We are often not aware of our mental models or the effects they have on our behavior: for example, “With a patient who starts with febrile syndrome of uncertain nature, we should not start antibiotic treatment” or “It is not a good idea to discuss errors while in the operating room”. “Mental models” of behavior in the organization are also deeply ingrained and mold the actions of individuals. For example, a resident of internal medicine who has a patient with bronchial asthma refractory to drug treatment and low saturation will not intubate until the medical assistant is present, because this is standard practice in their hospital. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the relationship among mental models, activities and results (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Mental models depend not only on the knowledge base but also on rules, assumptions, goals and beliefs. These models consist of the images and stories that we have in our mind about ourselves, others, the institutions and all aspects of the world. They are like a window that subtly distorts our vision; the mental models determine what we see. It is important to highlight that even errors are generally the result of “intentionally rational” actions. In other words, actions make sense according to how individuals frame the current situation and what their mental models are for dealing with the situation. Continuing with the previous example in which the decision was made to not provide antibiotics for febrile syndrome of uncertain origin, this decision might be surprising for the instructor if they do not consider that the condition might be acute meningitis. However, it will make sense if the instructor realizes that the student knows of an influenza epidemic and that the student had treated numerous patients that day for fever and other nonspecific symptoms.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The instructor's job during debriefing is to help participants examine their own assumptions and beliefs (that are taken for granted) in the practice of their professional work by making these mental models explicit and by analyzing their impact on actions and results. Once these models are known they can be repeated, if they have led to proper performance, or they can be changed for new models (for example, “Whenever I examine a patient with febrile syndrome, I should rule out meningeal symptoms and signs”), which leads to other actions (for example, giving antibiotics early) and improving the results (for example, preventing a deterioration in the level of consciousness). The results are states, such as heart rhythm, a participant who understands the etiology of the problem or a chaotic work environment. The instructor and the student generally have an implicit idea of the desired results, for example, that the patient remains stable and does not undergo cardiorespiratory arrest. The instructor explores with the student what mental models and related actions lead to specific results. Then, as indicated in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> by the arrows, the instructor collaborates with the student in developing alternative mental models and actions for the future.<a class="elsevierStyleCrossRef" href="#bib0120">24</a>There is convergence in the literature on the structure and number of processes that make debriefing an effective method for performing this reflection.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> In the initial phase, it seems appropriate to allow individuals to process their emotional states and synthesize the information. This starts a cognitive process in which the experience is analyzed and the mental models are understood. Once the mental models are revealed, the discussion and/or teaching are adapted to the learning needs of the individual or those of the team members. To complete the process, the experience is applied to everyday situations, and the lessons learned are summarized to improve future performance under similar conditions.<a class="elsevierStyleCrossRef" href="#bib0130">26</a>The main difference and application of this approach compared to the majority of traditional methods is that it distinguishes between two types of learning in healthcare organizations: single and double loop. In the single loop, the individuals, groups and organizations base learning on the correction of observed actions according to the difference between the expected and obtained results. In contrast, double-loop learning is based on questioning the values, assumptions and policies that lead to these actions.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> Modifying an action does not change the thought processes that originated it; therefore, its effect in preventing the action from being repeated in the future is limited. However, the recognition and adoption of new mental models helps us perform effective actions in the future and with a more lasting effect.<a class="elsevierStyleCrossRef" href="#bib0140">28</a>There is growing evidence in the scientific literature that supports this approach. Training with medical simulations lowers the incidence of catheter-associated bacteremia and its associated costs, maintaining these results a year after the procedure. What is striking about these results is that they reflect how a prior intervention with traditional learning methods (single loop) had a lesser and shorter effect.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> Training using reflective practice based on medical simulations not only improves the results of the application of clinical protocols but also improves the implementation of technical procedures. Thus, the percentage of obstetricians and midwives who are able to perform maneuvers properly increased (from 49% before training to 82% after training). This competence is maintained in 84% of these practitioners at 6 months and in 85% at 12 months.<a class="elsevierStyleCrossRef" href="#bib0150">30</a>ConclusionsThe development of expert clinicians requires deliberate practice, which differs from the simple repetitive practice of a task. It is a highly structured activity with the specific objective of improving performance and requires other components to be efficient. Effort and motivation by healthcare professionals over time is required to incorporate these skills into their daily activities. The identification of specific and significant learning objectives for the work performed is also essential. We also need educators trained in teaching techniques that enable the rigorous analysis of performance and who can provide specific and constructive feedback. In this respect, the teaching technique of debriefing constitutes an effective approach for understanding the reasons behind clinical activities and reveals the thought processes and mental models through which we attempt to explain what has occurred. It also helps analyze the impact of these mental models on our actions, to see whether they should be maintained or whether we should seek other models to achieve better performance in the future.Conflict of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres336656" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec318135" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres336655" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec318136" "titulo" => "Palabras clave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Introduction" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "The development of the expert healthcare professional" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "The origin of debriefing" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Reflective practice: methods and theories" ] ] ] 5 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 7 => array:2 [ "identificador" => "xack81085" "titulo" => "Acknowledgments" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-10-07" "fechaAceptado" => "2013-12-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec318135" "palabras" => array:5 [ 0 => "Debriefing" 1 => "Reflective practice" 2 => "Learning" 3 => "Education" 4 => "Clinical expert" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec318136" "palabras" => array:5 [ 0 => "Debriefing" 1 => "Práctica reflexiva" 2 => "Aprendizaje" 3 => "Formación" 4 => "Experto clínico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Debriefing is a rigorous reflection process which helps trainees recognize and resolve clinical and behavioral dilemmas raised by a clinical case. This approach emphasizes eliciting trainees’ assumptions about the situation and their reasons for performing as they did (mental models). It analyses their impact on actions, to understand if it is necessary to maintain them or construct new ones that may lead to better performance in the future. It blends evidence and theory from education research, the social and cognitive sciences, and experience drawn from conducting and teaching debriefing to clinicians worldwide, on how to improve professional effectiveness through “reflective practice”." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El debriefing es un proceso de reflexión riguroso que ayuda a los profesionales a reconocer y resolver los dilemas clínicos y de comportamiento puestos de relieve al cuidar de un paciente. Este enfoque facilita entender las razones para actuar como se hizo, revelando los mecanismos del pensamiento mediante los que se intenta explicar lo ocurrido (modelos mentales). Analiza el impacto de dichos modelos mentales en las acciones, para ver si es necesario mantenerlos o buscar otros nuevos que permitan obtener un mejor rendimiento en el futuro. El debriefing combina teoría y evidencia de la investigación en educación, en ciencias sociales y cognitivas, y en elementos de la experiencia de realizarlo y enseñar su uso a profesionales sanitarios para mejorar su rendimiento mediante «la práctica reflexiva»." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Maestre JM, Szyld D, del Moral I, Ortiz G, Rudolph JW. La formación de expertos clínicos: la práctica reflexiva. Rev Clin Esp. 2014;214:216–220." ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 842 "Ancho" => 1564 "Tamanyo" => 59979 ] ] "descripcion" => array:1 [ "en" => "The relationship among mental models, activities and results. Mental models depend not only on the knowledge base but also on the rules, assumptions, goals and beliefs. These models consist of the images and stories that we have in our mind about ourselves, others, the institutions and all aspects of the world. The smaller arrow indicates the “single-loop learning”, which is based on correcting actions. 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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The relationship among mental models&#44; activities and results&#46; Mental models depend not only on the knowledge base but also on the rules&#44; assumptions&#44; goals and beliefs&#46; These models consist of the images and stories that we have in our mind about ourselves&#44; others&#44; the institutions and all aspects of the world&#46; The smaller arrow indicates the &#8220;single-loop learning&#8221;&#44; which is based on correcting actions&#46; The larger arrow indicates the &#8220;double-loop learning&#8221;&#44; which is based on changing the mental models that give rise to the actions&#46;</p>"
        ]
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The performance of healthcare professions requires continuous evolution&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The exponential growth of new technologies&#44; procedures and diagnostic and therapeutic strategies&#44; the need to respond to countless productivity&#44; efficiency and quality indicators at the individual and institutional level&#44; the need to work in a team&#44; the increasing presence of older patients and their associated diseases&#44; as well as a transformation in the relationship between clinicians and patients and their families&#44; among other factors&#44; demand this constant evolution&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Organizations that seek to provide quality care require expert clinicians&#44; which is closely tied to the continuing development of their staff&#46; Healthcare educators seek methods to help these professionals reach and maintain levels of mastery that are demanded by the complexity and continuously changing nature of modern health care&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Traditionally&#44; training has been tied to the transmission of information in an organized and systematic manner by an outside expert&#44; along with the repeated practice of medical procedures and skills&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">However&#44; to benefit from the practice and reach their full potential&#44; adults depend not only on the amount of practice but also on how it is performed&#46; The theory of deliberate practice establishes a different approach and is defined as a type of highly structured practice that must meet certain requirements&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> We must interact with sufficient motivation&#44; autonomy and without pressure to acquire expertise&#44; approaches&#44; behaviors and skills in practice areas of interest to the practitioner&#46; To achieve the maximum benefit&#44; our own abilities must be trained to the limit&#46; The task should therefore represent a challenge and be well defined with extensively discussed and planned objectives and goals&#46; Additionally&#44; rigorous reflection on the performance is required&#46; The participation of educators trained in teaching techniques that provide specific and constructive feedback is therefore essential&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The training of teams using simulated cases studies&#44; followed by reflection on the performance&#44; has increased exponentially in the last decade as a teaching tool that adapts to the learning style of adult students&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Simulated clinical cases help establish realistic and specific objectives without putting patients at risk&#44; help students reflect on their performance in a structured manner and transfers the lessons learned to the daily work setting&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In this article&#44; we describe the relevant theories that give rise to reflective practice and the role of debriefing as a teaching technique to facilitate understanding of the reasons behind clinical performance&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">The development of the expert healthcare professional</span><p id="par0030" class="elsevierStylePara elsevierViewall">While experience is the basis for adult learning&#44; the Kolb theory of learning shows that this cannot occur without &#8220;rigorous reflection&#8221;&#46; In other words&#44; having experience is not necessarily the same as being an expert&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> &#8220;Rigorous reflection&#8221; is understood as a process that helps reveal and resolve clinical and behavioral dilemmas and areas of confusion that arise when dealing with a clinical case&#46; Learning is a process that begins when facing a situation that is not fully resolved with the traditional resources&#46; Individuals&#44; motivated by a feeling of uncertainty and discomfort&#44; seek to examine the experience&#58; What was the nature of the problem&#63; What were their intentions&#63; What did they do&#63; What happened&#63; In the process of observation and analysis&#44; there emerges the difference between intention and actual results&#46; This stimulates and motivates the professional to seek out new responses and incorporate more effective strategies that&#44; once conceptualized&#44; can be used in similar future situations&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">&#8220;Reflective practice&#8221; is a term coined by Donald Sch&#246;n who described it as the discipline of examining the values&#44; assumptions and knowledge-base that guide professional practice&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> If this could theoretically occur in any situation and be conducted on an individual level then it is normally not a relaxed or meditative process&#46; On the contrary&#44; it is usually a demanding challenge that usually delivers a better result when performed collaboratively&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Studies on perception and memory have shown that we are more conscious of the results of our thoughts than of the process that creates them&#46; Rational explanations can omit the unconscious attitudes that generally guide the thought process&#44; which hinders individuals in understanding what issues prevent them from improving&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The conditions in which reflective practice is associated uniformly with improvements in performance include the presence of well-defined learning objectives&#44; opportunities for deliberately practicing these objectives and reliable measurements for providing specific feedback&#44; which enable gradual improvements in performance&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In this context&#44; the main aspect of the learning process is often identified as debriefing&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> According to the criteria of the Center for Medical Simulation of Boston&#44; debriefing is defined as a conversation between two or more individuals who review a real or simulated event in which the participants analyze their actions and reflect on the role of their thinking process&#44; psychomotor skills and emotional states to improve or maintain their performance in the future&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Despite its importance&#44; the practice of debriefing varies significantly among institutions and instructors&#46; Thus&#44; some institutions and instructors perform a rapid assessment of the performance and provide specific feedback&#44; training &#40;coaching&#41; or direct teaching&#44; while others create an environment where the participants can reflect and openly discuss&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> In some cases&#44; the participants themselves perform the analysis without the presence of an instructor&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Current studies on the topic provide few guidelines on how to create an environment in which the professional feels both stimulated and psychologically safe to conduct a rigorous reflection after performing a clinical case&#46; Consequently&#44; there are various styles and approaches for practicing debriefing&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">The origin of debriefing</span><p id="par0045" class="elsevierStylePara elsevierViewall">Systematic learning constructed on experiences originated with the aviation industry of the 1970s&#44; as a response to numerous crashes of aircraft flown by highly experienced pilots in the absence of technical failures&#46; The aerospace authorities noticed that individual skills were not enough to ensure good flight outcomes&#46; In the following years&#44; first the U&#46;S&#46; Air Force and then NASA developed new methods to promote training in which an instructor &#8220;facilitates&#8221; a &#8220;debriefing&#8221; for the entire crew&#46; This process critically analyzes the events that occurred during the flight and the performance of the team&#44; even in cases that did not have fatal outcomes&#46; This inclusion of analyses in daily practice contributed to a drastic decline in the number of aviation accidents and deaths&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The U&#46;S&#46; Navy also initiated this learning approach to train personnel whose function was to face continuously changing conditions in a variety of circumstances&#46; After subjecting soldiers to exercises for practicing missions&#44; the Navy began performing &#8220;after action reviews&#8221;&#44; a method for extracting lessons from an event or project and applying them to other situations&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Based on these findings&#44; numerous corporations&#44; nonprofit institutions and government agencies reviewed the reasons why the methods for analyzing processes and projects commonly used to identify successes and failures had not penetrated the fabric of their organizations and become good practices and performance standards&#46; They discovered that most strategies for disseminating the analysis of results consisted of various types of reports to their employees&#44; such as documents and meetings&#44; which did not facilitate the effective exchange of ideas&#44; approaches and traditions shared by most people and that are transmitted from one generation to the next &#40;the organization&#39;s culture&#41;&#46; In contrast&#44; aviation and the navy provided opportunities for learning to their members through feedback cycles between analysis and action&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In 1999&#44; healthcare institutions undertook a substantial change in the manner in which health professionals were trained&#46; This was the result of a report by the American Institute of Medicine &#8220;To err is human&#8221;&#44; which revealed that up to 94&#44;000 people died every year in American hospitals due to medical errors&#46; One of their recommendations was to develop and assess new approaches for improving training and reducing errors&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In the subsequent years and following these and other recommendations derived from various studies and organizations&#44; a collaborative research project arose between the Center for Medical Simulation and the Harvard-MIT Division of Health Sciences and Technology &#40;Boston&#44; USA&#41; to study the method for transferring lessons learned by other disciplines to the healthcare setting&#46; As a result&#44; a method was proposed to help healthcare professionals develop self-correction habits to replace behaviors that hinder reflection and changes following clinical practice&#46; The professionals who learned to reflect in order to scrutinize their assumptions and mental routines were able to self-correct and improve their professional skills&#46; Conversely&#44; those without this ability tended to close up and ignore conflicting information&#44; maintaining ineffective habits in their clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Reflective practice&#58; methods and theories</span><p id="par0070" class="elsevierStylePara elsevierViewall">Reflective practice is the systematic and continuous process of achieving the maximum benefit from experiences by learning from them&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> In the healthcare setting&#44; there are various models for promoting this practice&#44; such as the technical analysis of critical incidents&#44; root-cause analysis and the use of mind maps&#46; The central idea of the theoretical model analyzed in this study suggests that the clinical results observed are a direct consequence of the actions of individuals&#44; and these actions in turn are the inevitable result of the thought processes with which the individuals interpret the condition&#44; processes called &#8220;mental models&#8221;&#46; Humans do not passively perceive an objective reality but rather perform a process to make sense of the experience&#44; a process in which they actively filter&#44; create and apply meaning to their environment&#46; The theory that supports this approach comes from cognitive science&#44; social psychology&#44; psychology and anthropology&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> &#8220;Mental models&#8221; are deeply ingrained assumptions&#44; generalizations and images that influence the way we understand the world and how we act&#46; The terms for referring to these models are numerous and include cognitive framework&#44; &#8220;reference framework&#8221; and &#8220;schedules&#8221;&#46; We are often not aware of our mental models or the effects they have on our behavior&#58; for example&#44; &#8220;With a patient who starts with febrile syndrome of uncertain nature&#44; we should not start antibiotic treatment&#8221; or &#8220;It is not a good idea to discuss errors while in the operating room&#8221;&#46; &#8220;Mental models&#8221; of behavior in the organization are also deeply ingrained and mold the actions of individuals&#46; For example&#44; a resident of internal medicine who has a patient with bronchial asthma refractory to drug treatment and low saturation will not intubate until the medical assistant is present&#44; because this is standard practice in their hospital&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the relationship among mental models&#44; activities and results &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Mental models depend not only on the knowledge base but also on rules&#44; assumptions&#44; goals and beliefs&#46; These models consist of the images and stories that we have in our mind about ourselves&#44; others&#44; the institutions and all aspects of the world&#46; They are like a window that subtly distorts our vision&#59; the mental models determine what we see&#46; It is important to highlight that even errors are generally the result of &#8220;intentionally rational&#8221; actions&#46; In other words&#44; actions make sense according to how individuals frame the current situation and what their mental models are for dealing with the situation&#46; Continuing with the previous example in which the decision was made to not provide antibiotics for febrile syndrome of uncertain origin&#44; this decision might be surprising for the instructor if they do not consider that the condition might be acute meningitis&#46; However&#44; it will make sense if the instructor realizes that the student knows of an influenza epidemic and that the student had treated numerous patients that day for fever and other nonspecific symptoms&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The instructor&#39;s job during debriefing is to help participants examine their own assumptions and beliefs &#40;that are taken for granted&#41; in the practice of their professional work by making these mental models explicit and by analyzing their impact on actions and results&#46; Once these models are known they can be repeated&#44; if they have led to proper performance&#44; or they can be changed for new models &#40;for example&#44; &#8220;Whenever I examine a patient with febrile syndrome&#44; I should rule out meningeal symptoms and signs&#8221;&#41;&#44; which leads to other actions &#40;for example&#44; giving antibiotics early&#41; and improving the results &#40;for example&#44; preventing a deterioration in the level of consciousness&#41;&#46; The results are states&#44; such as heart rhythm&#44; a participant who understands the etiology of the problem or a chaotic work environment&#46; The instructor and the student generally have an implicit idea of the desired results&#44; for example&#44; that the patient remains stable and does not undergo cardiorespiratory arrest&#46; The instructor explores with the student what mental models and related actions lead to specific results&#46; Then&#44; as indicated in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> by the arrows&#44; the instructor collaborates with the student in developing alternative mental models and actions for the future&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">There is convergence in the literature on the structure and number of processes that make debriefing an effective method for performing this reflection&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> In the initial phase&#44; it seems appropriate to allow individuals to process their emotional states and synthesize the information&#46; This starts a cognitive process in which the experience is analyzed and the mental models are understood&#46; Once the mental models are revealed&#44; the discussion and&#47;or teaching are adapted to the learning needs of the individual or those of the team members&#46; To complete the process&#44; the experience is applied to everyday situations&#44; and the lessons learned are summarized to improve future performance under similar conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The main difference and application of this approach compared to the majority of traditional methods is that it distinguishes between two types of learning in healthcare organizations&#58; single and double loop&#46; In the single loop&#44; the individuals&#44; groups and organizations base learning on the correction of observed actions according to the difference between the expected and obtained results&#46; In contrast&#44; double-loop learning is based on questioning the values&#44; assumptions and policies that lead to these actions&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Modifying an action does not change the thought processes that originated it&#59; therefore&#44; its effect in preventing the action from being repeated in the future is limited&#46; However&#44; the recognition and adoption of new mental models helps us perform effective actions in the future and with a more lasting effect&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">There is growing evidence in the scientific literature that supports this approach&#46; Training with medical simulations lowers the incidence of catheter-associated bacteremia and its associated costs&#44; maintaining these results a year after the procedure&#46; What is striking about these results is that they reflect how a prior intervention with traditional learning methods &#40;single loop&#41; had a lesser and shorter effect&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Training using reflective practice based on medical simulations not only improves the results of the application of clinical protocols but also improves the implementation of technical procedures&#46; Thus&#44; the percentage of obstetricians and midwives who are able to perform maneuvers properly increased &#40;from 49&#37; before training to 82&#37; after training&#41;&#46; This competence is maintained in 84&#37; of these practitioners at 6 months and in 85&#37; at 12 months&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="par0095" class="elsevierStylePara elsevierViewall">The development of expert clinicians requires deliberate practice&#44; which differs from the simple repetitive practice of a task&#46; It is a highly structured activity with the specific objective of improving performance and requires other components to be efficient&#46; Effort and motivation by healthcare professionals over time is required to incorporate these skills into their daily activities&#46; The identification of specific and significant learning objectives for the work performed is also essential&#46; We also need educators trained in teaching techniques that enable the rigorous analysis of performance and who can provide specific and constructive feedback&#46; In this respect&#44; the teaching technique of debriefing constitutes an effective approach for understanding the reasons behind clinical activities and reveals the thought processes and mental models through which we attempt to explain what has occurred&#46; It also helps analyze the impact of these mental models on our actions&#44; to see whether they should be maintained or whether we should seek other models to achieve better performance in the future&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "The development of the expert healthcare professional"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Debriefing is a rigorous reflection process which helps trainees recognize and resolve clinical and behavioral dilemmas raised by a clinical case&#46; This approach emphasizes eliciting trainees&#8217; assumptions about the situation and their reasons for performing as they did &#40;mental models&#41;&#46; It analyses their impact on actions&#44; to understand if it is necessary to maintain them or construct new ones that may lead to better performance in the future&#46; It blends evidence and theory from education research&#44; the social and cognitive sciences&#44; and experience drawn from conducting and teaching debriefing to clinicians worldwide&#44; on how to improve professional effectiveness through &#8220;reflective practice&#8221;&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El <span class="elsevierStyleItalic">debriefing</span> es un proceso de reflexi&#243;n riguroso que ayuda a los profesionales a reconocer y resolver los dilemas cl&#237;nicos y de comportamiento puestos de relieve al cuidar de un paciente&#46; Este enfoque facilita entender las razones para actuar como se hizo&#44; revelando los mecanismos del pensamiento mediante los que se intenta explicar lo ocurrido &#40;modelos mentales&#41;&#46; Analiza el impacto de dichos modelos mentales en las acciones&#44; para ver si es necesario mantenerlos o buscar otros nuevos que permitan obtener un mejor rendimiento en el futuro&#46; El <span class="elsevierStyleItalic">debriefing</span> combina teor&#237;a y evidencia de la investigaci&#243;n en educaci&#243;n&#44; en ciencias sociales y cognitivas&#44; y en elementos de la experiencia de realizarlo y ense&#241;ar su uso a profesionales sanitarios para mejorar su rendimiento mediante &#171;la pr&#225;ctica reflexiva&#187;&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Maestre JM&#44; Szyld D&#44; del Moral I&#44; Ortiz G&#44; Rudolph JW&#46; La formaci&#243;n de expertos cl&#237;nicos&#58; la pr&#225;ctica reflexiva&#46; Rev Clin Esp&#46; 2014&#59;214&#58;216&#8211;220&#46;</p>"
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                            0 => "J&#46;M&#46; Maestre"
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                      "titulo" => "La educaci&#243;n cl&#237;nica ayer y hoy"
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                            0 => "C&#46; Aguirre Errasti"
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