The obligation of debriefing in global health education

Abstract

Background: An outcome of globalization and internationalization in higher education in the health professions has been increasing global health placements. There is, however, a lack of literature on debriefing and support following these placements. The authors undertook a participatory project to develop peer support and debriefing in a global health nursing elective, during which this gap in literature was addressed.

Aims: The purpose of the project was to develop a peer support component of the course and revise the debriefing component based on results of a previous course evaluation.

Methods: The methods were guided by a participatory approach involving course alumni and included a scoping review and focus groups.

Results: The project resulted in development of: (1) a peer support statement and (2) a debriefing framework.

Conclusions: Key lessons about the obligation of appropriate debriefing for students returning from global health placements include importance of affective learning, a pedagogy of discomfort, and global health ethics.

Introduction

“When it comes to reflecting on complex decisions and behaviors of professionals, complete with confrontation of ego, professional identity, judgment, motion, and culture, there will be no substitute for skilled human beings facilitating an in-depth conversation by their equally human peers” (Dismukes et al. 2006, p. 24).

Skilled facilitation of an in-depth conversation, otherwise known as debriefing, is an important dimension of education in the health professions. It is a conversation amongst individuals who have shared a common practice experience that is intended to generate insights into that experience that may otherwise go by unnoticed. Such purposeful conversations rely on a clear structure along with skilled facilitation in order to maximize the opportunity for multiple layers of learning. Moreover, when professional practice experiences take place outside a controlled setting, far from one's home in resource-constrained communities, these conversations necessarily take on new dimensions. In this article, we suggest that the obligation of educators who lead such placements extends beyond concerns for students’ cognitive or skills-based learning alone to include attention to their psychological, emotional, and moral responses to socio-political and cultural aspects of the experiences. In short, debriefing after global health placements must be carefully considered and structured in order to attend to the affective dimension of cross-cultural experiential learning.

In this article, we examine debriefing from our perspective as nurse educators responsible for a global health elective course with international and Aboriginal community placements for nursing students at the end of their program. Debriefing has been a component of the course since its inception in 2006 but the structure has been generally informal. The debriefing component was revised as part of a project to develop peer support within the course. We begin the article with a literature review of debriefing in clinical education and cross-cultural placement experiences. Next, we describe the course and the peer support project, and present the debriefing framework that resulted from the project. Finally, we present the key lessons learned regarding our obligation as educators in ensuring appropriate debriefing for students whose clinical learning involves placements in global health.

Table

Practice points

There is an obligation of educators leading global health placements that extends beyond cognitive and behavioral learning to include the affective dimension of learning. International or global health placements offer rich learning opportunities for students that are enhanced with deliberate use of structured debriefings after placement. Similar to simulation-based learning, debriefing after global health placements can have an enduring effect in the development of clinical skills and reasoning. Debriefing after such placements must deliberately attend to affective and moral dimensions of experiences that include confronting realities of cultural competence and culture shock.

Debriefing in clinical education and global health

The clinical education literature is vast with many references to debriefing as a vital component of programs. In recent years, increasing attention to debriefing has been in simulation-based learning. In contrast, despite increased attention on global health placements, there is paucity of literature addressing the process of debriefing following these placements. However, existing literature does reflect assumptions of the necessity, purpose, and usefulness of debriefing, and offer important insights that inform best practices in this regard.

Clinical education and simulation

A significant emphasis in health professions education is hands-on learning, which necessarily involves debriefing, which centers on helping students to successfully integrate new knowledge and skills that are the foundation for future practice. As Overstreet (2010, p. 538) explains, “the principles of debriefing extend to any experiential clinical learning situation in which learners care for patients, respond to multiple stimuli, and make clinical decisions”. It is broadly understood as a reflective process that fosters clinical reasoning, critical thinking, and communication, and specific to simulation, helps to strengthen and transfer learning from an exercise to real life (Arafeh et al. 2010). From a pedagogical perspective, Parker and Myric (2010, p. 330) identify debriefing as “undoubtedly the most important” element of simulations. As such, it rests on assumptions of adult learning principles, experiential learning (Kolb 1984) and reflective practice (Schon 1983). Adult learning happens best when both cognition and emotion are involved, in situations involving task-oriented and interpersonal events (Fanning & Gaba 2007). Drawing from Kolb's (1984) foundational model, several authors have highlighted debriefing as that which serves to integrate stages in the learning process, from concrete experience, to reflective observation, to abstract conceptualization, and finally to active experimentation (Sims 2002; Fanning & Gaba 2007; Arafeh et al. 2010; Parker & Myric 2010). Debriefing, with its inherent structure and ambiguity, allows for personalized learning through experience by helping students to determine a situation's meaningfulness within their own lifeworlds (Sims 2002; Brackenreg 2004; Parker & Myric 2010). This is maximized, according to Neill and Wotton (2011), through a supportive and encouraging demeanor of facilitators and the creation of a safe and trusting environment.

Dismukes et al. (2006, p. 23) argue that students continue growing beyond basic education only when they develop the skill of critically retrospectively analyzing actions in simulation exercises and anywhere there is hands-on learning. This kind of critical analysis involves re-examining one's cognitive framing of the situation, thinking about what went well, what went wrong, and why it went that way. Moreover, Limoges (2010) found, in a study of the discursive practices of simulation, that nursing students felt more accountable for their knowledge in the simulation lab, than in an actual clinical practicum. They perceived themselves as “the nurse” in simulations versus being “the student” in real-life practice settings. This highlights that debriefing is an opportunity for synthesizing not only cognitive and behavioral learning but also for examining the psychological and moral sense of responsibility that students experience as part of becoming a professional.

For purposes of this discussion, it also bears noting that debriefing has a history in sectors other than education; namely in the military, emergency services, and research (Fanning & Gaba 2007). Its original use in the military was to obtain information about a mission from returning personnel, and then was used as a kind of “defusing” in order to minimize psychological damage of war-related events. This therapeutically focused debriefing, with an emphasis on the importance of telling the story of what happened, also developed as a peer model in emergency services to help mitigate the stress of traumatizing situations faced by police and firefighters. In experimental research, debriefing is carried out for participants who have been deceived as part of the study. Debriefing in this case focuses on informing study participants, after data collection, of the true nature of the research and their participation in it. In describing these non-educational uses of debriefing, the authors draw attention to relevant ethical considerations; that is, the facilitators’ duty to set parameters that create a space in which students feel respected, safe, and free to learn. They argue that the emphasis of debriefing ought to be on guidance not teaching, and facilitators seen as co-learners rather than authorities.

Models of debriefing have been offered, which in varying ways address the importance of tending to emotions and psychological safety so that cognitive and behavioral learning is maximized (Rudolph et al. 2007; Overstreet 2010). In the health professions, learning is thought to have an enduring effect when students have the opportunity to actively experience clinical situations that demand not only action and thinking but also making sense of their emotions in the moment (Cantrell 2008; Dreifuerst 2009; Overstreet 2010; Wickers 2010). However, Dreifuerst also cautions that while emotional release is important, it can also inhibit learning if it distracts from engagement in the whole experience. Therefore, a critical element of debriefing in clinical experiences is the accommodation and assimilation of emotions in learning. To this end, the debriefing process provides a means of professional development, supporting students to carefully consider what they are thinking, doing, and feeling in clinical practice situations. Furthermore, it provides an opportunity to examine the unintended consequences of cognitive frames and attitudes in clinical encounters (Rudolph et al. 2007 (italics added)) that may otherwise be left unexamined.

Some models also address the temporal nature of effective debriefing in terms of both the timing of the session after the learning experience and its duration (Fanning & Gaba 2007; Overstreet 2010; Parker & Myric 2010). The clinical experience will be seen differently depending on how much time has passed between the situation and the debriefing session (Lederman 1992; Overstreet 2010). Although most frameworks recommend debriefing be as soon as possible following the experience, some acknowledge the benefits of allowing more time for individual reflection in the form of written reports or journal writing before coming together as a group (Fanning & Gaba 2007). During the session, the facilitator must balance time in terms of appropriately shifting discussion away from personalized individual accounts to the whole-group perspective, and doing so without alienating the individual student by cutting him/her off (Fanning & Gaba 2007, p. 3).

The value of debriefing lies in its potential to help students in transferring their knowledge and skills learned in the simulation or clinical experience to other clinical settings and situations, and their transition from student to novice practitioner. However, despite the clear articulation of the value of debriefing in simulation literature, a gap exists in understanding how debriefing attends to cultural considerations. Specifically, debriefing in global health learning experiences where “culture” figures prominently warrants closer examination.

Global health education

While courses in “international” health have been common in the health professions for many decades, the new millennium has brought with it more focused attention on the globalization of health issues and related ethical considerations in research and education (Pinto & Upshur 2007; Greatrex-White 2008; Kinsella et al. 2008; Reimer Kirkham et al. 2009; Benatar & Brock 2011). Global health clinical education is addressed in the literature under a variety of terms, including: international and cross-cultural clinical practica or placements (Pickrell 2001; Grant & McKenna 2003; Mill et al. 2005; Balandin et al. 2007), international health-care or field experiences (Mackenzie 2002; Button et al. 2004; Lee 2004; Sandin et al. 2004; Jenkins et al. 2011), study abroad (Koskinen & Tossavainen 2004; Green et al. 2008), international practice education and student exchange (Duffy et al. 2003; Kinsella et al. 2008), international immersion, and cultural competence immersion (Rains Warner 2002; Ter Maten & Garcia-Maas 2009). Courses focused on Aboriginal health are also referenced, with “rural” or “remote” being used as descriptors for such in the Australian context (Mills et al. 2005; Neill & Taylor 2002; Webster et al. 2010). Reimer Kirkham et al. (2005) suggest “innovative clinical settings” to capture a constellation of practice placements that include international and Aboriginal communities and emphasize social justice as a major theme of student reflections about the experience. This range in terms speaks to the range in interpretations of this area of curriculum that generally seeks to raise students’ awareness of the globalization of health care. In understanding the purpose of such experiential learning and its inherent challenges, concerns of effective debriefing are called into question.

A commonly cited purpose of global health education programs is to provide students with an experiential opportunity for cultivating cultural sensitivity or competence (Duffy 2001; Pickrell 2001; Rains Warner 2002; Koskinen &Tossavainen 2004; Duffy et al. 2003; Mill et al. 2005; Green et al. 2008; Sandin et al. 2004; Jenkins et al. 2011). Cultural safety has been specifically proposed as a guiding concept for clinical education. It begins in the assumptions that health consequences of a colonial past on indigenous populations are witnessed the world over, and that understandings of culture and attitudes about difference are operationalized in health care practices (Browne et al. 2009; Gregory et al. 2010). These authors argue that critical frameworks are needed to guide and support students in their clinical learning to ensure that colonial biases and assumptions are examined as part of learning.

This intersects more broadly with the growing area of global health ethics (Benatar & Brock 2011) in terms of informing curriculum development that explicitly links social justice and equity to learning about practice in a globalized world. For example, Pinto and Upshur (2009) argue that the issues arising in international placements, such as extreme poverty, political instability, and dire health conditions without the commensurate resources create particular ethical dilemmas for students. Learning from these dilemmas can be supported through theoretical preparation including foundational notions of social justice, human rights, and vulnerable populations. Dwyer (2011) extends this to the ethical question of responsibility and responsiveness. Preparing students for their placement in regard to local society and health systems is also considered vital for learning (Duffy 2001; Grant & McKenna 2003; Lee 2004; Button et al. 2005; Ter Maten & Garcia-Maas 2009; Chavez et al. 2010).

Global health clinical placements bring with them significant challenges and stress for students (Koskinen &Tossavainen 2004; Ter Maten & Garcia-Maas 2009; Mill et al. 2005; Green et al. 2008; Sandin et al. 2004). The experience of living and working in an unfamiliar setting and culture is described as both a central feature of students’ learning and growth, and one of their greatest sources of anxiety. This has been framed by some authors as a struggle with cultural dissonance and culture shock (Pickrell 2001; Lee 2004; Button et al. 2005; Sandin et al. 2004; Jenkins et al. 2011). An important feature of immersion in a different culture is the feeling of being a “minority” (Duffy 2001; Grant & McKenna 2003; Button et al. 2005; Ter Maten & Garcia-Maas 2009). This sense of otherness can intensify struggles with difference that compel students to psychologically, emotionally, and intellectually sort out the dissonance they experience between closely-held values and what happens in real life contexts. Specific to the clinical placement setting, students are challenged by different health beliefs and care practices that conflict with their understanding of “universal” values of health care (Mill et al. 2005; Green et al. 2008). This experience of dissonance in turn leads to questioning one's own beliefs and assumptions. This is an important aspect of the process of moving towards a more sophisticated understanding of the complexities of global health issues (Duffy 2001). This highlights an inherent tension of the transformative learning in global health experiences: that becoming more culturally sensitive requires an often uncomfortable and troubling re-examination of deeply rooted beliefs (Koskinen & Tossavainen 2004; Lee 2004; Mill et al. 2005; Green et al. 2008), not only about clinical practice but also daily living. Then, how are students supported in this learning endeavor?

It is commonly understood that faculty support is necessary for students to manage cultural challenges and shifts in perspective (Pickrell 2001; Grant & McKenna 2003; Sandin et al. 2004; Button et al. 2005; Duffy et al. 2003; Mill et al., 2005; Balandin et al. 2007; Ter Maten & Garcia-Maas 2009; Webster et al. 2010; Jenkins et al. 2011). Debriefing, as an aspect of support, is identified as a factor in overall student satisfaction in global health education (Grant & McKenna 2003; Button et al. 2005; Webber 2005; Balandin et al. 2007; Green et al. 2008). Several authors emphasize the importance of debriefing after students’ return home, to help them with the integration of the experience, (Koskinen & Tossavainen 2004; Reimer Kirkham et al. 2009; Jenkins et al. 2011) to prevent it remaining an “unprocessed” and “isolated” part of their lives (Koskinen & Tossavainen 2004, p. 118). As a process that provides both educational and psycho-emotional support, Stockhausen (2005) explains that debriefing helps in facilitating a shift in identity as students integrate experiential knowledge, and positive relationships are required for the debriefing to be effective. Similar to simulation-based learning, debriefing after an international experience has an important role in professional and personal development in terms of transitioning from student to novice practitioner (Lee 2004). Also, timing is an important consideration. It has been suggested that while debriefing in the simulation context has best effect immediately following the exercise, debriefing a few weeks after an international experience enhances the final three stages of experiential learning: reflection, processing, and application, because time allows individuals to synthesize what they learned while away in the context of their lives and practice back home (McGraw & Palmer 2001; Mackenzie 2002; Sims 2002).

In summary, debriefing is a well-recognized component of experiential learning in clinical education and has been developed within various simulation models. However, while there is some acknowledgement of the need to consider student's personal and cultural background (Wickers 2010; Neill & Wotton 2011), more precise questions remain regarding how cultural assumptions and interpretations are operating during clinical encounters. Global health placements, by contrast, are a form of experiential learning that involves another degree of cultural dissonance not typically found in traditional simulation and clinical situations at home. This makes these placements fertile ground for transformative learning notably with regard to cultural competence and social justice. While this literature describes the value of debriefing in relation to cultural considerations, little of the actual process and structure is presented. In the section that follows, we share how we came to pay closer attention to our debriefing process of a global health practicum course offered in our nursing program through a student-alumni peer support project.

Critical perspectives in global health

Critical Perspectives in Global Health (CPGH) began as a strategy for incorporating global health into the undergraduate nursing program. The purpose of this elective course is to facilitate understanding of global health issues, social determinants of health, and provision of primary health care services in Aboriginal communities in Northern Canada and settings in Andhra Pradesh, India1. From its beginning, the course has been structured in four parts: selection of students; pre-departure preparation; placement; post-trip debriefing and evaluation. The six pre-departure seminars are balanced between theoretical concepts of post-colonial feminism, globalization, cultural safety, and global health ethics, and practical trip planning. Placements involve six weeks of clinical practice in the identified settings. Informal daily debriefing with peers and preceptors is strongly encouraged and begins as soon as students arrive in the setting. Students also are expected to journal and to write weekly emails to faculty who respond as reflective co-learners to the narratives shared. Upon return, students submit a scholarly reflective summary (topic of their choosing). Together these written forms of reflection serve as grounding for the group debriefing session, which is held approximately one month later. Some students choose to share directly from their journals though this is not mandatory. Debriefing, though informal in early years, has been seen as an opportunity for students to (re)frame their learning about practice in resource-constrained environments, cultural difference, and othering.

In interviewing course alumni as part of an evaluation project in 2009 (Chavez et al. 2010), two unanticipated themes emerged; namely, the importance of support over “teaching” and the need for more structured debriefing. Building on this, a faculty-funded project, Global Citizenship through Peer Support, was carried out in 2009–10, with the aim of creating a formalized student-alumni-faculty relationship that would serve as a supportive network for ongoing reflection throughout and beyond the global health placements. A participatory approach was adopted, which involved five course alumni co-leading pre-departure seminars, giving internet support during placement, and attending debriefing session. We used a focus group format, with a project assistant (PA) acting as facilitator, to capture our alumni-faculty team reflections on: (1) the process of working together in carrying out the course and (2) the form that peer support ought to take in future. These meetings were audio-recorded and transcribed. We individually reviewed transcripts and as a team synthesized ideas into themes. Two key thematic categories were identified, and the team divided into workgroups to draft recommendations for each: (1) defining peer support for this course including potential role of alumni and (2) developing a debriefing framework. What follows are the results of the latter.

We define debriefing as the provision of a structured supportive environment, post-placement, for students to share openly about their experiential learning during the placement – clinical, cultural, and personal - as well as their adjustment back to life at home after return. A quote from one alumnus captures the spirit of this definition:

“The trip as a whole was a bit overwhelming at first, in terms of what I have learned, and the impact it had on me personally and professionally. The debriefing session was very important because it helped me digest what happened during the trip, and hearing from the other students brought new perspectives to my experiences.”

The aims of debriefing are four-fold: to cultivate a sense of completion; to begin synthesizing the impact of this experience on future practice; to identify common global health issues for nursing practice; and to critically examine cultural dissonance experienced during placements for the learning it offers about multicultural work settings at home. As one alumni stated, “Yeah it's about students going away. But … they’re also obviously raising ethical issues, like, what's your role, are boundaries different there versus what we’re used to? …” This mirrors the purposes of debriefing identified in literature, which include synthesizing knowledge and skills, and psycho-emotional processing of experiences in regard to culture and attitudes about difference. Collegiality, reciprocity, and support are identified as key defining attributes of the process recognizing that the meaning of these concepts should be explored in pre-departure seminars, notably reciprocity from a post-colonial perspective.

The facilitator and student roles in debriefing are well described in simulation literature. Students returning from global health placements are the central participants in describing the rewards and challenges encountered during the placement. Faculty members, as facilitators of the process, are co-learners. As such, we recognize the need to approach facilitation with an openness to hearing a range of emotions expressed about met and unmet expectations of placements. This project also highlights the role of alumni as peers who support students while reflecting on their own previous experiences, thereby continuing their own transformative learning. Such reflection is evidenced in the following quote:

“It's important too that we as professionals stay engaged in finding our place … we have a unique opportunity to become involved with global nursing because we have all this sort of experience and it transcends cultural borders … it's in our best interest as nurses to want to be engaged in this process.”

Finally, the need to define a structure for debriefing is clear and together with alumni, we developed the debriefing framework provided in Table 1. We piloted it with the subsequent cohort of students while still allowing the session to evolve in a way that accommodated students’ choices about what they share, and critical debate of course concepts in light of lived experience.

Table 1  CPGH debriefing session format (adapted from Lovell-Hawker & Emmens 2004)

Purpose/description	Script
Welcome (10 minutes) Students are welcomed; agenda is introduced	Guiding “ground rules” help to maintain a supportive and safe climate for free-expression of thoughts, feelings, and reactions to the placement experiences. Suggested rules include: – one person speaks at a time – speak for myself, not for others in my group – respect others’ time to speak – participate as much as possible – be silent if it feels right – honor confidentiality.
Check-in (20 minutes) Brings group together in the here and now; to leave the outside world out there for the session.	This time is devoted to open sharing of stories. To start, please share your name, location of placement, and a brief statement about how you are feeling today about the placement experience. Bridge: are we ready to move on?
Debrief (one hour) There are a few questions to guide this part of the session. Students are free to pass if there is a question they do not feel they can answer.	1. Share one thing you learned well in your placement. 2. Share a high point of the experience. [prompt: what was most rewarding/gratifying?] 3. What was most surprising to you during those weeks in _______? 4. What was not surprising? 5. Share a low point of the trip or what was most troubling regarding nursing or health care in general. [prompt: can others relate to this?; Did you experience any feelings of loneliness, anger, or frustration? How did you deal with it?] 6. Thinking about the theoretical concepts introduced in the course, was there anything that was troubling in terms of your own reaction/attitude/behavior in a situation? If you feel comfortable sharing that, what was it? [prompts: What happened?; What was your first thought?; What did you think afterward?; How did you feel as it was happening? How do you feel now? If there's one thing you could go back and change or do differently, what would it be?] 7. Identify a point of culture shock. What did you learn from it? How did you adapt? 8. Share a high point, or one of the highlights of the trip overall. 9. Did you experience culture shock coming home? If so, share an example. How are you adapting now? 10. How do you anticipate this experience affecting future practice and/or career choices? 11. What lies ahead for you in the next 6 months? One year?
Check-out (30 minutes) A structured way to end the session; no new debriefing stories are included here.	To close we will take turns stating one thing that someone said in the session that “struck a chord” or feels valuable; something you will take away from this session.

In the introduction, we set explicit group norms that set a tone of trust and respect so that difficulties or challenges of the trip can be expressed without judgment. The Check-in also helps to create a sense of safety and support. The formal debrief begins with asking students to share a high point, or one positive experience in their learning, and then moves to experiences of dissonance. Students are encouraged to share thoughts about working in the context of difference and resource constraint. We explore positive and negative effects of the experience on their identity as nursing professionals, and finish with future oriented questions that elicit ideas about the careers that lay ahead.

Debriefing global health experiences: Lessons learned

We learned three broad lessons from our review of literature, work with alumni in understanding the peer support role, and our own experience in facilitation. These lessons are: (1) attending to the affective dimension of learning; (2) adopting a pedagogy of discomfort; and (3) seeing ethics as central to the discussion. Together they inform our perspective in seeing debriefing not as an option but rather, an obligation in our work as educators.

In paying close attention to the affective dimension of learning, there is value in drawing from non-educational sectors to inform debriefing related to global health placements. Experiential learning involves a strong affective component, particularly in relation to culture shock and immersion experiences in placements away from home. Emotions are acknowledged to varying degrees in simulation literature; notably being cited as important cues in clinical reasoning in the practice setting, in sorting out what one was thinking and doing in the exercise. In global health experiences, emotions have a powerful role in the experience of cultural dissonance. This dissonance is closely tied to deep-rooted values that are often understood not through rational thought but through general mood, anxieties, and other emotional cues.

Culture shock therefore holds a central place in global health debriefing, which is different from simulation exercises in which students are typically more familiar with their surroundings. Indeed the word “shock” holds an affective connotation. Additionally, the alumni in our project described culturally shocking experiences as emotionally charged both “there and here”. This highlights that while focus is on the trip, students also need space to share reflections on the sometimes more intense shock of the cultural dissonance experienced at home. Acknowledging dissonance during pre-departure preparation is important but will not suffice. An intellectualized discussion of culture shock must be followed up with frank conversation about how it was actually experienced to help students make sense of emotional responses and maximize learning. However, doing so also highlights the necessarily uncomfortable nature of many global health placement situations.

Theoretical preparation for placements, particularly in marginalized and resource-constrained locations, supports students in cognitively framing experiences within the socio-environmental and historical contexts of the particular setting. Specifically, an explicit critical social perspective on “culture” is valuable for understanding the experience of oppression for certain populations in the world. Yet, cultural meanings are so taken-for-granted that they often go unrecognized until cross-cultural experiences bring them to light. Furthermore, to have them challenged can stir a range of disquieting emotions. Therefore the debriefing process is a useful venue for calling students’ attention to culture, not as something external or objective, but as that which shapes each individual's way of being in the world (and therefore each health professional's way of being with patients/clients). In this sense, debriefing serves transformative learning by addressing troubling feelings that can accompany cognitive learning about “culture” from critical social perspectives.

The pedagogy of discomfort (Boler 1999) offers a reminder to educators: that our debriefing discussions with students about difficult issues in global health are not meant to be easy or comfortable, precisely because we are unpacking cherished values and beliefs. It assumes that this is necessary in order to learn a way of looking at the world that is more accurate and complex (Boler 1999). Applied to debriefing, the pedagogy of discomfort reminds educators to expect strong emotions in the session. And, strong emotions often link to sorting out the moral dilemmas faced during placements. Furthermore, it is important to debrief with one another as educators in order to safely question our own strong emotions as we work at enacting the values and principles we teach.

Our third lesson is a point less emphasized in the literature. Through debriefing, students are learning ethics. In the global health placement settings described here students not only experience cultural dissonance related to pragmatic daily living but are also confronted on a deeper level with issues of social injustice, disparity, and oppression. While an academic introduction to these concepts is embedded in the theoretical preparation of the course (and the larger curriculum), recognizing such phenomena as they are happening, particularly in health care delivery, demands a moral response that is not always easily determined. Notably, the stories shared during our debriefing were most often those involving the moral dilemmas students either handled well or felt powerless to address. A discussion of global health ethics and related personal moral dilemmas encountered during the placement serves in learning about professional practice in the given setting and at home.

Conclusion

We acknowledge this was a small project that lasted just one year, and that a formal evaluation of the framework is now needed. However, it has been a good starting point for considering how debriefing figures into excellent global health programming in health professions education. A point beyond dispute in the literature stands out: skilled facilitation is required for effective debriefing. We argue that skilled facilitation in global health education means creating safe space to talk about culture shock in non-“politically correct” ways, to name the positive and negative emotions associated with culturally and morally demanding experiences that students encounter during their placements so that they can manage and learn from them.

Debriefing is an important venue for supporting students’ professional development. Further research is needed to examine its specific aspects as part of experiential learning in global health. Fanning and Gaba (2007) suggest exploring fundamental issues such as whether debriefing is always required, how group and individual debriefing formats differ and to what end. Such research may also include evaluation studies of the effectiveness of debriefing in terms of students’ transition to practice, or minimizing negative effects of culture shock. Specific debriefing for placements in Canadian Aboriginal communities also warrants closer attention. In conclusion, the obligation of educators leading global health placements extends beyond cognitive and behavioral learning to include the affective dimension of learning. In our deliberations as global health educators offering such placements, we need to ask how our debriefing process attends to the often discomforting yet also rewarding experiences in morally challenging placement settings around the world.

Acknowledgements

We gratefully acknowledge the course coordinator, Freida Chavez, for her unreserved support, and project assistant, Shawna Ardley, for her tireless energy in contributing to all aspects of the project. We are also indebted to course alumni Stephanie De Young, Daniel Dugard, Jacqueline Lau, Ivana Matic, and Nancy Yi for their hard work and valuable input.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

The project was financially supported by a grant from the Nursing Education Research & Development Fund of the Lawrence S. Bloomberg Faculty of Nursing.

Notes

Notes

1. Since the time of first writing, Aboriginal placement options have been moved to the final consolidation course, however the pre-departure and debriefing format remains the same as that of the CPGH elective.