The Journal of Continuing Education in Nursing

Original Article 

Incorporating the Reflective Pause in Simulation: A Practical Guide

Timothy C. Clapper, PhD; Kim Leighton, PhD, RN


Many articles exist today espousing the value of debriefing following a simulation or gaming event. Although debriefing, a reflection-on-action strategy, is important, a useful reflection strategy may accentuate the reflection-in-action process that is arguably even more important than the debriefing. In this article, we explain a concept called the reflective pause and how it can be used during simulation cases to lead the learners to the objectives and enhance the learning process. We provide a review of the literature concerning reflection-in-action and ways that the reflective pause may be used during key learning events. The reflective pause is relatively absent from the simulation-based education lexicon. Used effectively, the reflective pause may become one of the most valuable learning strategies in a simulation educator's tool belt. [J Contin Educ Nurs. 2020;51(1):32–38.]


Many articles exist today espousing the value of debriefing following a simulation or gaming event. Although debriefing, a reflection-on-action strategy, is important, a useful reflection strategy may accentuate the reflection-in-action process that is arguably even more important than the debriefing. In this article, we explain a concept called the reflective pause and how it can be used during simulation cases to lead the learners to the objectives and enhance the learning process. We provide a review of the literature concerning reflection-in-action and ways that the reflective pause may be used during key learning events. The reflective pause is relatively absent from the simulation-based education lexicon. Used effectively, the reflective pause may become one of the most valuable learning strategies in a simulation educator's tool belt. [J Contin Educ Nurs. 2020;51(1):32–38.]

The use of simulation in health care has grown considerably in recent years. Today, it is nearly unheard of and unacceptable for a health care provider not to have practiced on simulators or in simulation environments before being credentialed to treat real patients. Some simulationists may consider the debriefing to be one of the most important aspects of simulation-based learning. However, no matter how well developed the experience, learning does not and cannot occur without real-time reflection-inaction. As Montessori (1949, p. 35) posited, learning involves an active reasoning process and the use of memories. Far ahead of her time, she described the transformation process—it is like a chemical process in the brain, where we hold onto memories in the construction process and apply the knowledge in our environment.

This article introduces a term that may be absent or unfamiliar in the simulation community lexicon—a term referred to as the reflective pause. The reflective pause technique applied during training events allows the facilitator to draw out thoughts and beliefs from the learners about the content and behaviors that are occurring in real time. Doing so allows the learner to clarify and reinforce concepts that are critical to the learning objectives, thereby maximizing the learning experience.

This article provides an overview of reflection. It also highlights the three coaching styles described by Schön (1987) and how reflection is embedded in each of these techniques. Finally, it describes how the reflective pause has been used in numerous locations and settings to amplify the learning process before making several suggestions for incorporating the reflective pause technique into a simulation-based lesson plan.

Defining Reflection

Reflection, as defined by Boyd and Fales (1983), is “the process of creating and clarifying the meaning of the experience (present and past) in terms of self ” with an outcome of a “changed conceptual perspective” (p. 101). Although we have read about the importance of debriefing and its impact on learning (Lederman, 1984; Levett-Jones & Lapkin, 2014; Nelson & Leighton, 2010; Shinnick, Woo, Horwich, & Steadman, 2011), less is known about the significance of encouraging reflection during the learning experience. It is important to facilitate an ongoing reflection process during individual learning sessions and as a valuable component of mastery learning, which takes place over a longer period (Bloom, 1968a, 1968b).

Reflection-on-Action Versus Reflection-in-Action

Argyris and Schön (1992) were theorists and philosophers known for their work of learning organizations— in particular, explaining features of human action. They identified two outcomes of learning, including identifying the match between intention and effect and correcting misunderstandings. Corresponding with this view, they described the reflection process that can coincide with an experience. Reflection-in-action occurs during an experience. It may include a self-generated metacognitive process (“okay, I've completed this step, so now I must…”) and, as this article elaborates on later, can also be facilitator generated. The reflection-on-action process is most often facilitator generated and, as the term implies, follows the experience. In the simulation community, this reflection-on-action process is often referred to as a debriefing. Debriefing offers opportunities for both feedback and reflection to occur. Sawyer, Eppich, Brett-Fleegler, Grant, and Cheng (2016) suggested three forms of debriefing that can occur with a simulation experience: facilitator-guided post-event debriefing, self-guided post-event debriefing, and facilitator-guided within-event debriefing.

The first is based on the military after-action review. The facilitator leads a discussion that helps the learner reflect on the event that occurred including reactions at critical points in the event. Self-guided post-event debriefing is not as the title suggests. Although it is generally facilitated by group discussion among the participating team members, the cues and prompts for the feedback are provided externally through a facilitator. A small pilot study by McMullen et al. (2016) may best describe the third form, facilitator-guided within-event debriefing. The learner, often the leader, can request a pause in the simulation and request what they refer to as an on-demand debriefing. The facilitator guides the learners to think through the problem, assists them with gaps in knowledge through constructive feedback, and helps them to identify team resources that may be available to them (p. 159). Van Heukelom, Begaz, and Treat (2010) compared in-session and post-event debriefings in a retroactive pre–postsurvey research protocol. In that research, the facilitator could pause the simulation as needed to provide feedback and correct errors in judgment or performance. Learners did not feel that the pauses affected the realism of the simulation; however, they did report that the post-event debriefing helped them to learn more effectively than the in-session debriefings.

Coaching Styles to Facilitate Reflection

As noted by Argyris and Schön (1992), our social systems are based on “rewards and penalties, rather than internalization, according to which the individual tries out new behavior and makes it part of his repertoire” (p. 82). In a recent article dedicated to developing situational interest during an instructional session, Clapper (2014) expressed the importance of a reflective pause for the purpose of generating inquiry in a subject and providing a feedback mechanism during the learning process. In that article, Lewin's position is emphasized that learning involves planning, action, ongoing reflection, and fact-finding; as noted by Bruner, this learning process can include three stages: acquisition, transformation, and evaluation. To facilitate this process, a facilitator, acting as a learning coach, may use one of three coaching styles described by Schön (1987): the follow me approach, the experimentation approach, or the hall of mirrors.

The follow me approach can be an effective way of ensuring that learners understand the right way of accomplishing a procedure. This may be especially important for the health care community because outside of certain tasks such as basic life support or advanced cardiovascular life support, there is little consistency in the manner in which providers are taught to perform many procedures. In the follow me approach, the coach models the behavior and the learners imitate and try out the procedure themselves. Although the health care community sometimes ridicules the “see one, do one, teach one” model, there are tremendous benefits to this model when it is done correctly. Part of doing this well implies that ample time is provided for practice and reflection using various types of simulation and students are not practicing on real patients.

The joint experimentation approach described by Schön (1987) occurs after agreed upon goals are determined between the coach and learner. After agreeing on a mutual definition of goals, the coach may provide a demonstration that is followed by practice. Demonstration and modeling are important because they set the parameters for learning to ensure progression toward the agreed upon goal (Williams & Dunn, 2008). The practice portion of this approach is unique because it can take both the learner and the coach down different paths. In health care, this approach may be seen in a simulated cardiac arrest. Actions, dependent on the cardiac rhythms displayed on the monitor, include shocking or not shocking the patient, and administration and dosing of medication. Hence, this approach requires the learner to move down a particular path not known ahead of time to the learner. The coach and learner engage in joint experimentation with realistic simulations to see what happens as the variables change in the case.

The third coaching approach, the hall of mirrors, is ongoing during a learning session and is highly reflective. As described by Schön (1987), through an iterative manner, the coach-facilitator assists the learner with reflecting on their actions, including their current frames of reference, beliefs, and actions as the learner is engaged in practice. We may see this approach in use when teaching procedural tasks using partial-task trainers. Advantages of this approach may include constant feedback and correction, whereas disadvantages might include the learner losing tacit momentum in the procedure and disruption in learning. However, as shown in research by Van Heukelom et al. (2010), these disruptions may not have the negative effects that some health care simulationists thought they would.

Framing Schön's Mental Model

Conceptualizing these three approaches is not difficult when we consider the possible rationale and beliefs behind Schön's views. As a professional who delved into the subject of reflection, Schön did not solely focus on how a learner may perform differently in the future based on a reflective action occurring after an experience. Although he posited value for the reflection-on-action or debriefing process, he saw even greater benefit in reflecting on the experience while the learner still had an opportunity to learn in the situation or experience (Schön, 1984). Being aware of the need for reflection that is a part of the learning process may be the reason why some researchers (McMullen et al., 2016; Van Heukelom et al., 2010) expressed the importance for debriefing during the experience. Accordingly, Schön observed that as one becomes more familiar with their practice, the knowledge and skills become tacit and the professional “misses important opportunities to think about what he is doing” (p. 61). Some participants very familiar with the venue and procedure may reach a “knowing-in-action” stage and they can miss things in the experience that can develop into errors (Schön, 1984, pp. 234–235). This stage or condition could preexist prior to the participant entering the learning experience, yet misunderstandings can be uncovered through the reflection-in-action process. A reflective pause could be used to determine where learning is occurring, where things need to be corrected or guided to another path, and where the behaviors may need to be supported further.

The Reflective Pause

The reflective pause is a deliberate pause during any portion of the learning experience used to facilitate immediate reflection. It can be an important part of the formative learning process described by Bloom, Madaus, and Hastings (1971). Formative learning includes assessment throughout the learning experience, ongoing feedback, and opportunities for self-correction that are supported by the facilitator. When assessment occurs throughout the experience, feedback is provided and self-correction is supported (Bloom et al., 1971). The timing of the pause may be planned ahead of the simulation/gaming case or experience. However, facilitators may find it more beneficial to apply the pause judiciously, after observing a certain number of behaviors needed to ascertain whether the learner is moving toward the learning objectives. Likewise, the facilitator may observe a critical teaching moment that should not be left until the end of the experience. Consider the novice learner (Benner, 1984) who only knows the rules of how to provide care but has little to no experience implementing care in context. This lack of contextual experience in a realistic environment can create barriers to learning, but this can be addressed and resolved through use of a reflective pause. Continuing a formative learning experience that progresses based on the consequences of a novice learner's error may lead to contextual interference (Clapper, 2011, p. e78) including confusion, anxiety, and ultimate failure to meet the learning objectives. Continuing the experience despite the error does not allow an opportunity for learners to self-correct; therefore, the decision to pause for reflection should be made based on the facilitator's knowledge of the learner's educational needs, abilities, and general level on the novice to expert scale.

The reflective pause may be used effectively in any of the three coaching styles described by Schön (1987). It may occur as a one-time event or during multiple points of an experience, depending on the instructional model and other variables discussed later in this article. Recall that the follow me approach involved the coach modeling the behavior and the learners imitating and trying the procedure themselves. This model may be best suited prior to the case or simulation scenario when the skills and procedures are being taught and practiced. An example may be teaching intraosseous infusion (IO) placement to inter-professional teams as part of cardiac code team training. After demonstrating IO placement, the facilitator would allow the learner to practice the procedure. At times determined by the facilitator, the reflective pause may be applied, and the learners asked to reflect on their performance as it relates to the learning objectives. The reflective pause can include feedback such as that provided with deliberate practice (Ericsson & Pool, 2016), but ultimately it is used to facilitate the metacognitive process related to the current thinking and behaviors. Example reflection questions include:

  • “After two attempts to place an intravenous therapy, you asked the provider to start an IO. What did you base your decision on?”
  • “I noticed that you had difficulty with pushing fluids after placing an IO. Talk to me about the possible reasons why fluids may be restricted and some troubleshooting interventions you might use.”
  • “I noticed that you elected to practice placing the IO in the tibia. What would be some advantages and disadvantages of this and other IO sites?”

In the latter question, the reflective pause could be especially useful for encouraging practice and use on other sites, which may be necessary during the simulation case or during real-life events. The pause allows inquiry into current thinking, including degrees of comfort and personal beliefs behind the learner's practice, and ensures that learners are meeting the learning objectives. Again, this may occur as a one-time event or during multiple points in an experience.

Multiple pauses may not be much of an issue during skills-building or procedural building sessions prior to the simulation case. However, during the simulation case or scenario, pauses are minimized to prevent disrupting the flow of patient care, the realism of the experience, and understanding of the consequences of incorrect actions (Oriot & Alinier, 2018). The joint experimentation approach described by Schön (1987) may be especially applicable here. After the skills and procedures have been practiced, learners may be asked to incorporate the new behaviors into a realistic clinical simulation scenario. Using the cardiac code case again as an example, the facilitator may initiate a reflective pause immediately after all initial team roles have been assigned and people have begun to perform a certain set of behaviors in those roles. Perhaps most importantly is the immergence of a situational leader, who may be first to respond and assign roles and responsibilities prior to the arrival of the designated leader of the code team, who normally possesses a higher scope of practice. Applying the reflective pause after the initial roles have been assigned ensures that learners did not accidently fall into those roles and their actions are deliberate and intentional, which reinforces the learning objectives. Reflection questions might include:

  • “I noticed that the first person in the room assigned positions to team members entering the environment, while providing them with an update of the situation. Please talk to me about how that took place.”
  • “Closed-loop communication is extremely important during a code so that the leader and the team maintain a shared-mental model about what has and has not been accomplished. What were some examples of closed-loop communication that you used or witnessed so far?”
  • “Tell me about other opportunities for closed-loop communication that could have been applied in this situation.”

Similarly, Schön's (1987) hall of mirrors approach is invaluable for teaching skills or procedures as it may include multiple pauses for reflection to ascertain the learner's thoughts and beliefs, including the reasoning behind the decisions they are making. Referring back to the IO example, learners are provided a demonstration and opportunities for practice. After reaching a level of competency and comfort with the procedure, the hall of mirrors approach is used to emphasize critical thinking skills and, in this case, the rationale behind the steps or procedure. Assisting the learners with this level of understanding can prepare them for variable clinical situations or when troubleshooting becomes necessary. Reflection questions might include:

  • “One of the things we talked about as a complication that can occur with IOs is compartment syndrome. As you are practicing together in this course, what are those things that you are cognizant of that can assist you with preventing complications such as this?”
  • “The IO comes with three different sized needles, and your team has been practicing with the blue needle (25 mm length). When might you consider using the pink needle (15 mm length) or the yellow needle (45 mm length)?”

Why We Need to Teach Our Learners and Ourselves to Stop and Think

For more than 35 years, we have witnessed simulationists and gamers across disciplines publish about the usefulness of reflection-on-action or debriefing (Crookall, 2011; Kriz, 2008; Lederman, 1984; 1992; Lyons et al., 2015; Petranek, 2000; Steinwachs, 1992; Stephanian et al., 2015; Verkuyl, Lapum, St-Amant, Betts, & Hughes, 2017). As shown in the literature review, researchers (Kikkawa & Mavin, 2017) have found large variation in debriefing beliefs and practices among practitioners attributed to factors such as methods, terminology, and professional focus. Although debriefing may improve the learning process, it is the experience and an ongoing reflection process that causes us to reconsider what we know or do not know about a subject.

As reflection-in-action is a natural part of the learning process, learners can benefit from the reflective pause, which enhances the value of the educational intervention by helping them to understand why they made a certain decision at a specific moment in time, based on understanding of what they were experiencing. In addition, when reflecting on how knowledge is constructed, it is important to realize that unlearning is a part of the learning process (Crossley, Ashby, & Maddox, 2013; Tsang, 2008, p. 8). Feedback that is partially based on the learner's response can induce the unlearning process (Crossley et al., 2013, p. 31). Reflecting on and comparing the new material with what is currently known allows learners to add to or alter existing frames of knowledge. However, as learners, health care providers may have a difficult time letting go of what they currently know or do for a few reasons. This difficulty letting go may be related to the need to feel safe in their comfort zone, not wishing to engage in the risk that is sometimes involved in learning, thinking that they do not need to change, or feeling that the new information could potentially interfere with the shortcuts they have created through expertise (Rushmer & Davies, 2004). This means that there is likely to be an emotional connection associated with unlearning or letting go of the existing ways of doing things. Aside from that issue, there is the matter of learning the wrong knowledge, skills, and procedures. If not assessed and caught during the experience, these behaviors and mental models can go unchecked and uncorrected during the debriefing. The learner can depart the session at risk of performing unintended harm.

For serious gaming or simulation learning events, the question remains, why wait until the end of the session to find out what the learners understand or failed to grasp? Learners can leave a learning session confused or unclear about the content. Skills and actions can be performed correctly without any true understanding of why they are being performed or how to adapt them for various situations or patient types. A good facilitator will assess throughout a learning event to ensure the learners are meeting the learning objectives (McTighe & Wiggins, 2012; Williams & Dunn, 2008). Reflection-in-action serves as a form of assessment as learners are asked about what they are thinking, at a specific moment in time, while managing a specific situation. The reflective pause provides for clarification that can affect future performance and understanding throughout the remainder of the scenario. To summarize, the reflective pause can be a valuable tool for facilitators for assisting learners with reaching the learning objectives, achieving mastery, encouraging self-reflection and growth, and self-regulating during current and future learning experiences.

Making It Work

A reflective pause can be planned or unplanned. During a simulated event, we find it useful to engage active observers and participants in the experience as a form of assessment and a way to strengthen the desired behaviors. In the team-based courses taught by one of the authors, multiple teams are taught in each session. While one team performs in a simulation, another team actively observes the case. The active observers, as they are referred to, are briefed ahead of the simulation scenario or case. They are expected to assess and take notes using the checklist provided to them so they can assist the facilitator with debriefing the team during and following the event. The reflective pause benefits the team that is currently going through the experience. During the pauses, the learners have an opportunity to confirm their behaviors and self-correct as needed. It also benefits the active observers, who have an opportunity to reflect on the experience and compare the participant's performance with a set of standards. They will rotate or transition from active observers to participants, so this reflective pause and the debriefing will be especially meaningful for them as they prepare for their own simulation case.

Some simulationists may have concerns about interrupting the simulation as that can cause the participants to disengage and not be able to engage again after the pause; however, no credible evidence supports such a position. Our own experience with thousands of simulation sessions and the research that does exist (Van Heukelom et al., 2010) supports the position that the learners are able to reengage following pauses in the simulation. The reflective pause does not eliminate the value of a reflection-on-action process or debriefing. It does, however, potentially strengthen the debriefing. Depending on the simulation scenario, participants, having received some useful reflection and feedback, have an opportunity to self-correct and practice applying adjusted understandings and behaviors to meet the learning objectives more accurately. The reflective pause provides a sort of springboard to additional questions that may solidify participant understanding and assist them with transferring the new behaviors to their actual clinical settings. Some debriefing questions may include:

  • “We recognized the importance of closed-loop communication, and during the pause in the simulation, we highlighted the actions of the physician assistant (PA), who acknowledged the order to place an IO after two failed attempts at intravenous therapy. The PA placed the IO and then shared with the leader and the team that the IO was placed and could be used. What other examples of closed-loop communication did we observe during this simulation?”
  • “During the pause in the simulation, we observed the critical timing of tasks and the role that each member played to ensure that they were accomplished to enhance the survivability of the patient. Tomorrow, next week, next month, you find yourself in a situation in which you are responding to a cardiac emergency as part of a code team. Talk to me about those critical first steps and roles that are assigned and why they are so important to the success of your team.”

The reflective pause need not be isolated to a verbal cue or a simulation. One of the authors also uses it during regular classroom instruction sessions. A handout titled Reflection Now® is handed to the learners and they are asked to write down three things that they learned at that point in the learning session and how it may be used in their own work environment. This reflection process causes them to think about what they are learning and how useful it can be for them. Reflecting on their current knowledge and practice and how the new information will apply is an important part of the constructive or transformative learning process.


Every learning experience counts. Learners will depart the educational session with some form of knowledge, but as noted, it may not be quality outcomes. When learners enter the classroom or simulation space, they enter with existing ways of knowing. However, their frames of reference could contain incorrect information that can lead to poor performance. Rather than propagating these errors for the sake of playing out a simulation to the end, we suggest that using a reflective pause will allow for early recognition and reflection on the performance that allows for positive learning outcomes. If the topic is important enough, it is worth it to stop and pause to help the learners reflect on what they are doing and how it compares with what they know. The reflective pause is a technique that facilitators should consider to improve the quality of the learning experience.


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Dr. Clapper is Assistant Professor of Education in Pediatrics, Weill Cornell Medical College, and Director of Education, Weill Cornell Medicine New York-Presbyterian Simulation Program & Center, New York, New York; and Dr. Leighton is Executive Director, ITQAN Clinical Simulation & Innovation Center, Hamad Medical Corporation, Doha, Qatar.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Timothy C. Clapper, PhD, Director of Education, Weill Cornell Medicine New York-Presbyterian Simulation Program & Center, 525 East 68th Street, New York, NY 10065; e-mail:

Received: December 21, 2018
Accepted: August 06, 2019


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