Simulcast Journal Club June 2017 – Beer Pressure


Introduction : 

Simulcast Journal Club is a monthly series heavily inspired by the ALiEM MEdIC Series.  It aims to encourage simulation educators to explore and learn from publications on Healthcare Simulation Education.  Each month we publish a case and link a paper with associated questions for discussion.  We moderate and summarise the discussion at the end of the month, including exploring the opinions of experts from the field.

The journal club relies heavily on your participation and comments, and while it can be confronting to post your opinions on an article online, we hope we can generate a sense of “online psychological safety” enough to empower you to post!  Your thoughts are highly valued and appreciated, however in depth or whatever your level of experience.  We look forward to hearing from you!

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Title :  “Beer Pressure

The Case :

Nitin squeezed into the booth next to Brad and the rest of the crew then raised his beer in a friendly salute.  It was great to have the whole faculty out for a drink for once.

“Cheers to a course well run.” smiled Brad, and they both quenched the thirst of a long day’s debriefing.

“Thanks Sensei.” Grinned Nitin, “I really enjoyed today.  I think I’m getting the hang of this.”

Brad nodded earnestly.  “The student has become the master, I reckon.  I was really having trouble in that second debrief, after Alex mismanaged that sepsis case so badly, I was worried we wouldn’t be able to address all the issues that came up.  I hope she wasn’t too upset, I really felt she needed to know about her inotrope mixup and the whole albumin thing.”.

Nitin paused.  He was concerned about that debrief too, and Brad had been so concerned about Alex’s performance he’d completely forgotten the nurses present in the scenario.  If truth were told, he tended to pay less attention to the nurses when he was debriefing, maybe because it was harder to relate to their concerns?  But Brad had taught him so much in the last few months.  It seemed arrogant and disrespectful to start doling out advice this early in his career.

Brad leaned back and sipped.  “It’s hard to get honest feedback sometimes.”.  He looked at Nitin perceptively, perhaps having registered his mentee’s hesitance.  Brad had flaws but a lack of emotional intelligence was not one of them.

Nitin punched him gently on the shoulder.  “You did great Mr Miyagi.  Next round’s on me.”.

The Article :

Cheng, Adam MD, FRCPC, FAAP; Grant, Vincent MD, FRCPC; Huffman, James MD, FRCPC; Burgess, Gavin MD, FRCPC; Szyld, Demian MD; Robinson, Traci RN; Eppich, Walter MD, Med

“Coaching the Debriefer: Peer Coaching to Improve Debriefing Quality in Simulation Programs”

Simulation in Healthcare : The Journal of the Society for Simulation in Healthcare.

Publish Ahead of Print, POST AUTHOR CORRECTIONS, 20 May 2017

DOI: 10.1097/SIH.0000000000000232

 

Discussion
While we may espouse the importance of a healthcare workplace free of intimidating power differentials and flourishing with open highways of transparent communication, the realities of achieving that lofty goal can perhaps be recognised by reflecting on the simple challenge of giving peer to peer feedback between simulation educators.

 

This month’s article is a call to arms from a group of simulation gurus regarding the power of peer coaching, and provides strategies to overcome the complex social pitfalls involved in providing honest feedback to your colleagues and friends.

 

What’s your experience been with peer feedback in your simulation program?  What are your reflections after reading this article?  Has it changed your approach?

 

References :

Cheng, Adam MD, FRCPC, FAAP; Grant, Vincent MD, FRCPC; Huffman, James MD, FRCPC; Burgess, Gavin MD, FRCPC; Szyld, Demian MD; Robinson, Traci RN; Eppich, Walter MD, Med

“Coaching the Debriefer: Peer Coaching to Improve Debriefing Quality in Simulation Programs”

Simulation in Healthcare : The Journal of the Society for Simulation in Healthcare.

Publish Ahead of Print, POST AUTHOR CORRECTIONS, 20 May 2017

DOI: 10.1097/SIH.0000000000000232


About Ben Symon

Ben is a Paediatric Emergency Physician. He is based at The Prince Charles Hospital in Brisbane. In 2014 Ben was the first Simulation Fellow for Children's Health Queensland, and assisted in the statewide roll out of the SToRK Team's RMDDP program. He currently teaches on a variety of paediatric simulation based courses at Lady Cilento Children's Hospital on paediatric resuscitation, trauma and CRM principles. As a relatively new simulation educator, Ben has a growing interest in encouraging clinical educators to be more familiar with simulation research.


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9 thoughts on “Simulcast Journal Club June 2017 – Beer Pressure

  • Ben Symon Post author

    To start the conversation off, I’m going to reflect on the article and also my experiences with peer feedback.
    This article was a road map for me on how to implement peer to peer feedback within simulation education, and the key take home points for me were :

    1. The importance of pre-briefing peer feedback and setting clear expectations.
    2. The benefits of using a consistent structure for feedback.
    3. An explicit discussion that outlines some of the social hierarchy problems that exist within peer to peer feedback.

    In terms of critiquing the article (an ironic and heavy challenge for me, given the theme of the month and how remarkably kind, nurturing and generous several of the authors have been to me in my brief simulation career), I feel like there are some pretty high expectations in there that reflect the world class facilities the authors are working in [and potentially their frames of reference and expectations]. From a simple time management perspective, some of the more rough and tumble simulationista’s out there are working in resource limited environments and the extensive prebrief suggested is not always going to be viable.

    This article was particularly interesting for me because as I’ve become a more experienced teacher, I’ve met a few highly prominent educators who are pining for feedback, but their local preeminence isolates them in an ivory tower whereby they feel they only ever receive praise (and they’re secure enough to not find that very useful).

    Some of the challenges for me in providing peer to peer feedback have been :

    1. Sometimes people will ask me for feedback, but on occasion I suspect they were actually asking for validation and my critique provides unintended offense. My approach has always been that if people ask for honest criticism then I provide honest criticism and avoid disingenuous praise, but it is not infrequently received with disappointment. I think our culture has subtle traps with regard to expectations for feedback, particularly because we tend to overvalidate and praise our friends as a form of social currency that then devalues honesty when providing feedback within professional environments.

    2. Sometimes I will have people want feedback (not necessarily Simulation related), but I am concerned that the feedback they actually need to hear can be psychologically challenging for them to receive. On occasion I think honest feedback can become an identity threat. If somebody sees themself as a great educator or great clinician, and it is hugely central to their sense of self esteem and identity, it can be really hard to have those honest and hard conversations even when you think they’re really important. Because even a light critique can shatter that’s person’s sense of self. I’ve found this the hardest type of feedback to do, and in all honesty I usually instead choose to avoid giving it.

    3. It’s pretty easy to have honest learning conversations with people who are reflective. It’s very hard to have a learning conversation with somebody who is pre-contemplative. But much like the overconfident medical trainee who thinks they’re nailing it when they’re not, it’s often the pre-contemplative people who need that feedback the most. It’s hard! I also think sometimes people who come to teach on a course are doing it in their own time, or on a voluntary basis, or are giving up important clinical time to do it, and they don’t actually want to learn how to improve on the day, they just want to be appreciated. And feedback is then seen as particularly offensive in that context.

    4. When there is a large power differential between multiple colleagues providing peer to peer feedback, I think inconsistent feedback can become destructive. I’ve heard from people receiving feedback from experts is that it can be confusing. Experts achieve a level of confidence whereby they can be very comfortable giving feedback that directly contradicts another expert’s opinion on the same debrief. While the OSAD and the DASH can be useful structure points to provide consistency to debriefing feedback, there will always be a level of subjectivity. This can lead to learners receiving conflicting, confusing information that puzzles them but they ironically still feel the need to please these experts. Their inability to fully comply with two bits of conflicting advice can lead to them becoming defensive and resenting the feedback process entirely.

    Having said that, a colleague of mine implemented a debriefing feedback loop into our CRM course that incorporated elements of DASH and OSAD into it. It was very well received and debriefers (who have often had no training beyond on the job experience) were keen for the learning. Time, in that instance, remained the primary issue given the next sim was usually already rolling. This article will be useful at looking at how to structure the ‘where’ and ‘when’ of that feedback a little more formally. (I’m looking at you Louise!)

    I’m looking forward to other people’s responses, I hope I’m not the only one having these challenges!

  • Rowan Duys

    Thanks again to Ben and team for another great case and article. And Ben for your thoughts. I identify with many of the problems you relate…

    Ahhhhh, feedback, is there anything quite so useful, and yet quite so difficult to give….or receive? But I suppose the simulationista (I heard it on Simpodcast, so it must be a real word, and I like it) journey, particularly the debriefer learning curve, is all about acquiring the tools and skills to deliver meaningful, impactful feedback, whether with your own words, or by facilitating the learner to give it to themselves. Isn’t it? So I see peer-coaching as just another opportunity to use communication for education or to be educated.

    As always, and I’m sure there is sound educational theory behind this feeling, it is very helpful when someone else takes your lived experience, unpacks it, and describes it within a framework that is easy to understand and relates to the existing literature on the subject – Big thanks to the authors! I engage in peer coaching, usually in a ‘targeted feedback’ manner, but not always with a specific framework or guiding principle in mind. I found the structure for coaching/feedback described very helpful, and I will definitely attempt to focus on these issues ie that feedback should be:
    1. Specific
    2. Based on accurate observations
    3. Relate to a ‘best-practice’
    4. Give a rationale for why behaviour should change

    Where our team is not going to be able to comply to suggestions from the article is to get formal coaching on coaching. Since a stated motivation for the paper is that peer coaching may be more affordable or attainable than formal debriefing courses, I was concerned by the suggested need to obtain training in feedback, debriefing rating tools etc etc before using them safely. But perhaps this describes a difference in culture inherent in our system in South Africa, probably enhanced by a difference in resources. When we carve out time and monetary resources in the Sim Team, I think we’ll probably choose to spend them elsewhere. Though I understand the sentiment and inherent risks of using these techniques when not trained. Suspect we’ll just have to be comfortable with the mistakes we’ll make.

    Which I suppose brings me to describe how peer-coaching has played out in my own practice. The sim-educator with whom I work most frequently and I have committed to robust feedback on all things work-related and through trodding the same path frequently, plus the fact that we’re good and honest friends, have created psychological safety that enables a coaching relationship that I believe is successful. (By the way, the multiplier effect of a ‘sim-buddy’ needs to be described, it has made all the difference.)

    But I have also had some failures with peer coaching. A newly trained instructor, when I observed him at one of his first training events described how having me there made him so nervous that he forgot some of the structure of his planned debrief and didn’t perform as he would’ve liked. Since I have only a year or so experience on him, I didn’t think that I could’ve had that effect. The lesson I will take away, from this article and that experience, is perhaps to be more explicit next time that I will be circulating, observing and giving feedback. Creating psychological safety in that context is more difficult than I thought, and requires a different approach for each learner…challenging.

    On a practical note, how are other teams structuring their sim sessions to allow for debriefing the debriefing or debriefer coaching? Do you send your learners on extended coffee breaks between each sim?

    Looking forward to hearing other views on how peer-coaching has played out for people.

    • Ben symon

      Thanks so much for your thoughts Rowan. I agree on the power of the SIM Buddy, I think those long lasting relationships can really create such a nurturing sense of psychological safety and the friendships involved can really empower a sense of being on an exciting learning journey together. I think it also shortcuts some of the need for extensive ground rule establishment, once the culture is in place.

      In terms of feedback loops, my friend Louise had instituted specific allocations post the 6 Sims in our course for people to debrief the debrief. In the context of a tightly run course, this became resource heavy since there was less faculty to run the next SIM, as it would run immediately post the previous debrief. The debrief debriefs therefore became rushed due to the need to contribute to running the next scenario but it was still valued anyway.

      One thing I found helpful as well was to identify some learning goals with my SIM Buddy as well, like one time we decided to work on being more learner centred. It allowed us to critique each other explicitly and focus our observations.

  • Bishan Rajapakse

    Thanks for the great article, and Ben for the forum to discuss. I have shared some reflections from reading the article and a question to the authors below 🙂

    —After reading article by Cheng et al on “coaching the debriefer”, it struck me that perhaps peer-based coaching and training in feedback/debrief could be one of the key strategies in creating collaborative workplace cultures.

    REFLECTIONS – peer based learning/coaching

    I remember tweeting/ suggested at a conference last year about when disussing the topic of mentorship – “what about “co-registrar (resident) metorship”. I guess in a simple tweet you are only communicating the tip of an iceberg of experience/ideaology. What I really wanted to discuss, over and avove the 140 character line was at least in part addressed in this weeks simulation article. Under the heading of “Why peer coaching?” – when Cheng et al have gone on to suggest;-

    “When applied in the context of medical trainees, peer feedback enhances work ethic, communication skills, and teamwork.[30–32] Peers tend to provide feedback on behaviors that otherwise might have gone unnoticed by superiors.[33]
    There are many interpersonal interactions occuring in a busy clincial enviroment. If we are to be aware of the non-verbal communcitaion, subconscious biases that may play out unbeknownst to the actor on the clinical stage, then it would stand to reason that only someone there with you could also see what was happening.”

    Whilst this article is pitched at “education of faculty” (on techniques in teaching and feedback, based on direct observation of peers), perhaps this concept can be applied right through residency and training. I wonder if it is during this residency/training years that the culture of feedback/constructive discussion, or lack thereof is developed?

    THE ARTICLE – Questions for the author.

    I think the article provides a good framework for how “peer feedback” can be structure. Some of the practical challenges are highlighted in the paragraph under “Who can be a coach?”

    “In its purest form, peer coaches are colleagues with equal levels of training, knowledge, and stature within the healthcare hierarchy. In reality, differences among peer coaches and educators will exist. Power differentials may create tension that threatens psychological safety, which encourages a shared belief among peers that their learning environment is safe for interpersonal risk taking.[44]”

    My Question to the author is “can this framework be applied to peer coaching on bedside teaching / on the floor teaching?”

    The reason is that in a busy shift based enviroment there often isn’t that opportunity to debrief, largely because there would only be certain relationships where trust is enough to do so. This would perhaps mean that the same clarification of expectations of faculty members, prior to shift would have to occur, for the same reasons surrouding potential conflict of experience, knowledge and seniority.

    I wonder who peer-based debrief would work EM clinical shifts? Has it been studied? For example, would there be value in a culture were there was debrief betweeen faculty members regarding education and training for that shift, using the frameworks suggested in this article?

    Regardless of the answers to these questiosn, I was very encouraged in reading this article that seems to be base on a noble educational vision. It seems to be a step in a positive direction:-

    “By encouraging respectful interactions between colleagues, peer feedback supports mutual development and builds a culture of professionalism.[34–36] Much like simulation-based education took time to gain traction before becoming mainstream, peer coaching for debriefing can become the norm if embraced and implemented in a thoughtful fashion.”

    Best wishes
    Bishan

  • Rowan Duys

    Thanks for your comments Bishan and Ben.

    Ben, I like your idea of setting a clearly defined goal for the educators before a session. I imagine it helps create the context for the peer discussion and gives a focus for the *specific feedback* related to *accurate observations* against *agreed standards* with an *expressed rationale* (Ed – performing spaced practice from earlier comment)

    Bishan, thanks also for bringing the conversation to clinical debriefing. I like it, and will continue to try to use the language and stance of sim-based education as I interact with colleagues….and people in general.

    I also wanted to through into the discussion the importance of faculty development, and I see peer coaching as an important part of that in our own setting, as an enabler and multiplier when establishing a sim-programme. You could argue that without a mannikin, your immersive sims are a dead in the water, but I think thats not really true. So other than a few tech requirements, the need to grow faculty has got to be the most important problem to solve to launch and sustain a meaningful simulation effort. I can feel our programme becoming more powerful with each new faculty member we sign on and train up.

    If anyone has references for good papers describing the early phases of faculty development in a sim-programme, please share, we’re trying to collect some data around this at the moment and I haven’t found a huge amount.

    Keep the ideas coming folks

  • Adam Cheng

    Hello Ben, Rowan, Bishan, Vic and Simulation podcast followers

    Great discussion – so many excellent points brought up thus far in this thread. I love the ideas and experiences that you’ve all shared!

    I want to highlight the comment brought forth by Rowan and Ben, that peer coaching can be facilitated by having one (or both) members of the peer coaching partnership to share their personal goals ahead of time. This might be as simple as “I’d like to work on closing performance gaps today”; or “Can you focus in on my reactions phase – I tend to gloss over what the learners say and struggle to incorporate their issues into my debriefings”; or “Please give me some feedback on how I construct my advocacy-inquiry questions”. Providing an objective or two at the beginning of the day (or prior to the session) helps the coach hone in on specific behaviours, thus making it easier to provide meaningful feedback. It also allows the targeted coaching sessions to be super brief yet helpful! That’s the best part .. sometimes there is only 2 or 3 minutes …. but that might be enough if the coach knows what to look for. I’ve shared a slide on twitter from one of our recent workshop that illustrates where peer coaching might fit in within a day of simulations.

    Coaching can be difficult when there is a power gradient between the coach and facilitator, and as Ben has described, when the recipient is not receptive of feedback. I’ve found that showing vulnerability can sometimes be an effective strategy to overcome these challenges. To show vulnerability, I will offer up myself to be the first recipient of feedback …. and share my own personal goal(s) for improvement on that day, while ensuring it is something they feel comfortable providing feedback about….. while this may not always work, it does often open the door for more effective feedback conversations down the line when the roles are reversed.

    Regarding Bishan’s question – can peer coaching be used in other contexts (eg. bedside teaching etc)? Definitely! The literature certainly supports the benefits of peer coaching. I believe many of the issues described in our paper will likely translate to other contexts. The importance of setting expectations, communicating goals, teaching how to give feedback etc will all be important components that contribute to the success of the program. I would love to see a study on this …..

    Keep the discussion going … so great hearing about everyone’s experiences with peer coaching!!

    Warmest Regards
    Adam Cheng

    • Ben Symon Post author

      Thanks for the comments Adam, I really appreciated your suggestion of role modelling vulnerability in order to break down barriers to feedback. I can imagine it must be challenging for you to get peer feedback sometimes? I think one challenge I’ve had is when senior educators ask for feedback but I feel I have little of value to contribute to their expertise, as such I appreciated your contemplation regarding finding a learning goal that allows your peer to provide valid feedback that they are comfortable giving. This psych safety stuff can get pretty meta!

  • Tanya Bohlmann

    Thanks Ben for another great journal club article to contemplate.
    I feel like there is something serendipitous about the timing of your articles – your recent choices seem to perfectly reflect and/or highlight specific issues I have been grappling with in the development of our new Sim program and my own evolving experience as a simulation educator/debriefer. I also suspect that Rowan Duys may be an old friend from South African university days so your journal article serves multiple purposes this month – reuniting old friends too..?
    As mentioned by everyone else so far, this article has provided some great ideas and frameworks for peer coaching. After having had the recent fortunate opportunity to attend a debriefing workshop run by the extraordinary and inspiring Vic Brazil, I have had the gnawing feeling that my own debrief skills will still require years of refinement to reach expert level (doesn’t everyone want to be like Vic?). The good news is that Vic (and this article) have provided many practical tips to improve and reflect on practice. Reading about other ‘simulationista’ (credit to Rowan for adding this to our sim lexicon) peer-coaching experiences is also invaluable.
    In our setting, the opportunity exists for more targeted peer coaching than ‘debriefing the debriefer’ as our time and resource allocation is somewhat limited on the day of the event but we could definitely aim to allocate more time for longer debriefs every now and again – particularly to tackle more complex concepts. We have been using a more informal (and admittedly unstructured) approach to peer feedback with the hope of becoming more organised with time. Fortunately, we have established a good zone of psychological safety and my ‘sim-buddy’ Suneth is equally reflective, enthusiastic and keen for a constructive peer-learning partnership. At the moment, we have a faculty meeting post sim event to try work out areas for improvement but we have yet to formalise the peer feedback component into this. The article’s structured debriefing feedback form will no doubt also prove exceedingly useful when coaching our current and future Simulation Education registrar(s) to improve their debriefing skills. Watch this space!
    I think mastering the skill of giving difficult or unwelcome feedback is something that will remain elusive without considerable (deliberate) practice and role-modelling but it’s good to know that most people still struggle or feel uncomfortable in this domain, and that there are numerous resources out there to help us continue to navigate this tricky territory.

    • Victoria Brazil

      Thanks every one for wonderful thoughts and comments. Seems another great choice for discussion Ben.
      (and Tanya you are very generous)

      I agree with others perceptions and realities as to what gets in the way of this. At my program we have a constant merry go round of enthusiasts who ‘want to do some sim’ and of course we are always grateful for assistance and honestly need the numbers .However both natural proclivities and level of preparation for effective debriefing vary. The undergrad simulation i do is especially busy – its a numbers game when you have 100 in a cohort, so a languid debrief the debrief isn’t going to work. My approach (not especially by design 🙂 is therefore to leverage the co-debriefing and encourage short conversations and directive feedback between scenarios and in breaks in the day. We have managed to build an expectation and ‘norm’ around these processes, although still far from perfect

      Its interesting that we have (and acknowledged in the paper) such hierarchy issues in our sim educator communities – when this is one of the key issues we are debriefing about with participants !

      So i appreciated how this paper gave me a name for this ‘targeted peer coaching’, and described drawing upon structured tools to give a debriefing checklist. That is a very useful table. My only suggestion is that each of those issues is presented as a yes/ no performance criteria , and i would have liked some examples of the actual debriefing scripts or words that might prompt a discussion about the issues? Overall I found it a very practical article in the ‘how to’ area, but ( as per usual for these authors) grounded in theory and long experience.

      Rowan I don’t think your position is so unique. Very few have the luxury of highly developed and well penetrated simulation faculty development programs. And if we are super honest we don’t actually know if or how much ‘harm’ there really is from the untrained debriefer?

      This article connected with some recent thinking I’ve had about peer coaching for clinical work, and highlighted nicely in a recent DFTB post. (http://dontforgetthebubbles.com/supervision/) Atul Gawande also wrote about his experience of having a coach in the operating room (http://www.newyorker.com/magazine/2011/10/03/personal-best)

      Yet again our sim experience may give us better habits in our clinical practice

      Thanks again for all the comments

      vb

      .