Simulcast Journal Club September 2017 – Trouble in Paradise


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!

Copy of Journal Club

Title :  “Trouble in Paradise 

The Case : 

It was hot and humid in the taxi ride home, and Dave was feeling petulant.   A month away from his clinical duties had seemed like a dream come true, but the realities of spending time with the in-laws at their home in South-East Asia had rapidly hit home.  He had thought dating someone from a different cultural background would be easy, but as he was fast learning, there were challenges he hadn’t anticipated. And it was not bringing out the best in him.

“God I wish your parents would listen to me sometimes.  I tell them I’m not hungry, so they order a banquet, and I keep telling them I’m full but they keep pushing food onto my plate!  Then they look frustrated when I don’t finish the ridiculous amount of food I told them they shouldn’t have ordered in the first place! And this was just lunch!  They’re already planning dinner and that’s like… 2 hours away!  They’re driving me nuts!”. 

“Gweilos eat to live.  Asians live to eat.” joked Jess. 

Dave fumed. “I get it.  I get it.  But for 2 weeks I keep saying I don’t want any more food and they keep ignoring me!  It’s like your parents care more about looking generous than actually hearing what I’m saying.” 

“Aren’t you always going on about Frames with your sim stuff?” soothed Jess.  “You’ve got to see it from their perspective.”.   

“They’re pretty old school, and in their culture it’s important to be ‘hak-hei’.  It kind of means that as a guest you’re supposed to be polite and decline offers a few times before accepting them.  When you keep saying no, they just think you’re being hak-hei and load up your plate.” 

“That’s not what frames are about at all.” lied Dave crankily. 

Frames were only fun when he was the one uncovering them. 

The Article : 

Chung HS, Dieckmann P, Issenberg SB.
It is time to consider cultural differences in debriefing.
Simulation in Healthcare : The Journal of the Society for Simulation in Healthcare.
2013 Jun;8(3):166-70. doi: 10.1097/SIH.0b013e318291d9ef. 

 

Discussion :  
As healthcare simulation and debriefing expertise has flourished around the world, it has been acknowledged that a lot of debriefing framework shares a heavily westernised perspective.  In Chung et al’s article, the authors explore cultural differences in debriefing strategies and discuss traps for new players who are debriefing in a cultural environment different from their own. 

What has been your experience with debriefing in different cultures?  Is the traditional ‘debriefing with good judgment’ framework based on a particularly western perspective?  If so, how can it be adapted to aid learning objectives in other cultures? 

  

References : 

Chung HS, Dieckmann P, Issenberg SB.
It is time to consider cultural differences in debriefing.
Simulation in Healthcare : The Journal of the Society for Simulation in Healthcare.
2013 Jun;8(3):166-70. doi: 10.1097/SIH.0b013e318291d9ef.


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.


10 thoughts on “Simulcast Journal Club September 2017 – Trouble in Paradise

  • Victoria Brazil

    Thanks again Ben for raising an issue that (at least in my experience) is rarely discussed explicitly, despite having simulation learners and providers from diverse cultural backgrounds in my institutions.
    From the outset – i recognise that I am from the dominant cultural group in Australia and experience plenty of white privilege, and so probably miss nuances that are in front of my face.

    The article is sharply focused – and makes explicit the ‘frustrations’ Westerners have when working with those from Asian countries in particular – when our conversational techniques and values seems to not hit the mark. While most realise we’re missing something, and may have well intended respect – i suspect few of us delve deep enough to make a conscious change to our approach based on cultural norms.

    The article explores the concept more generally and draws on the richer field of cultural studies to help understand it. Unsurprisingly this then also raises other issues like medical hierarchies and gender norms in different cultures.
    I’m not sure about the ‘assumed debriefing characteristics in differnt parts of the world’ and whether that actually helps in a debrief. We know that cultural awareness and safety is more complex than that. Differences are also more nuanced. I know for example that in Australia ‘teasing’ humour can be used as a supportive strategy in the right debriefing context, whereas i was once admonished for suggesting that as a strategy in a US based discussion (and anyway they spell it humor, without the ‘u’ 🙂

    In Australia we might also consider indigenous cultural norms, which (unfortunately) we’ve been able to avoid confronting in simulation debriefing because of so few indigenous healthcare providers. That is changing and yet I’ve rarely had discussions about that with simulation providers in this country.

    The paper provides directions for future research in this area. Although published in 2013 – i found only 3 papers subsequently published that cite this one.
    Not a sexy topic? or too hard?

    My take home – stop and think about cultural differences in debriefing.

    I hope some with more experience in this area contribute to the discussion, including those simulation providers who bring a different cultural background to their ‘Western’ debriefing programs

  • Nemat Alsaba

    Thanks Ben and Victoria for bringing up this significant topic yet less talked about.

    This topic is challenging even for the people with multicultural background or “hybrid culture “such as myself (born in Saudi Arabia, grew up in America and ended up in Australia) and practiced Medicine in both Saudi Arabia and Australia.

    I agree with the author that the debriefing phase of SBL is an interesting indicator for culture as our aim from any reflection in the debriefing phase is to partially change “a culture or a value in the learner knowledge, skill or attitude “
    The author also brings to the spot the concept of “Mitigated speech “(an attempt to downplay the meaning of what is being said) where you need to be polite while deferring to authority or seniors even if a disaster is happening! and gave an example of a Korean airplane crash in late 1990s.
    Learning and understanding any culture and acknowledging its legacy is the first step before implementing any changes and addressing any challenges.

    Some of the things that I have encountered myself as a learner …When I was doing an Ortho Registrar Job at Saudi Arabia I have asked my consultant during our morning rounds a question and he looked at me unimpressed and said to me in front of the whole team “ you are not allowed to ask me questions , if there is any information or knowledge that I think you need, I will give it to you “ this reflects the issue of hierarchy in medicine ,showing your elder or senior the respect they deserve by not speaking in their presence until given the permission in a masculinity society.
    This has confused me at the begging of my learning journey but now I look at it and realise that it is the same issues that Chang el al discussed in his article in different cultures as well “Asian culture “.
    Another thing That I should acknowledge is that when you change your work environment you also change your behavior to fit within the culture of the new team and it doesn’t matter from what cultural background you come from. I would like also to share my own personal experience or struggle…When I started practicing medicine in Saudi I had to learn and respect one of the cultural communication gestures (Not looking your seniors, elders in the eye when you communicate with them and on top of that as a female not to have eye to eye contact with a male). This became a challenge for me when I moved to Australia and I had to learn to” Unfreeze “and change my communication skills and believe it or not it was not easy!
    I would like to further explain the difference between senior and elder culturally. Senior is a person who have more knowledge and experience than you regardless of age, ethnicity or gender. A teacher is one of the highly respected careers and one of the known axioms in the Arabic culture “I am a salve of him who has taught me one single letter “which obviously makes it difficult for the learners to disagree or challenge their” master “opinion or knowledge.

    The paper also gives a good contrast between the silent and active participants in (PBL or SBL) both in the western and non-western culture. It also shed the light on Hostede’s Theory to apply 3 visible manifestations of culture in our SBL (choose the appropriate terminology of simulation in that culture, to encourage multicultural networking and collaboration and fully understanding and respecting the cultural background of your participants)

    The paper ends by bringing up a storm of interesting questions that needs multinational and multicultural research collaboration to make A CHANGE in the culture of SBL and debriefing a multicultural participants and teams.

    • Ben Symon Post author

      Thanks Nemat for such an interesting and unique perspective.
      I have to confess I am struggling with a bit of an internal conflict regarding this issue.
      On one end I want to respect other cultures and be able to debrief successfully in a multicultural environment, ensuring that my learners achieve learning objectives and walk out of the sim feeling it was worthwhile.
      On the other end, I feel pretty strongly that there’s a lot of research that hierarchical power differentials can be counter-productive to patient outcomes if taken to an extreme.
      I feel like while we need to be aware of differences in cultural conversational strategies and approach a debrief with an open mind about how those conversations may flow, we also have a responsibility to advocate for patient safety and encourage healthcare workers to consider speaking up or challenging the norms of their culture if that culture propogates silence in front of authority. Or am I just projecting my western opinion on other cultures with a bit of western arrogance? Tricky.
      I need to contemplate some more I think, but it’s a challenging conundrum.

  • Mary Fey

    Ben, this is such a great topic – thanks for putting it on the table. I remember the first time I experienced a clash of cultures in debriefing. My very western, very American style of communication caused a learner to become upset. In retrospect, I see that she was taken aback by my direct discussion of her mistake. One of those painful learning experiences…

    Fortunately, cultural diversity now comes to many of us within our learner groups. One learner group can easily include people from multiple cultural backgrounds. The debriefer can’t possibly know and prepare for all possible cultural encounters. Korean culture, amazingly, has 6 different levels of conversations! I’m sure I’d pick the wrong one…..
    So, this turns the lens inward – to the debriefer becoming aware of personal biases that can influence us: that quiet learners are “not participating” (or maybe she’s a “receiver oriented” communicator)…..that everyone needs to learn to speak up (or perhaps I need to figure out the best communication pathway for learners from cultures who espouse “mitigation talk”). In other words, as a debriefer, it’s important that I examine what’s influencing me. As is so often the case, the frames of the debriefer are as important as the frames of the learner.

    Values, discussed as “the core of culture” describe “broad tendencies to prefer one state of affairs over another”. A shift in values, then, is what debriefing often drives towards. That is a tall order, and a journey that can’t be undertaken without trust. Connection, based on respect, is imperative if we are to build trust with our learners. How critical it is to respect our learners in all their complexity, including their cultural values.

    A qualitative study beckons…..

  • Adam Cheng

    Thanks for sharing this article – a debriefing classic!

    I remember reading this article for the first time, thinking how it hit home, explaining the reasons behind my struggles in debriefing when travelling abroad.

    What I still find incredibly challenging is adapting my predominantly “western” style of debriefing to fit the cultural norm – which may differ depending in where I M teaching. For example, when I went to China several years back I found it really hard to engage learners in reflective discussion. I tried to set (new) expectations in the prebriefing, allowing more time for silence, using eye contact, asking more directive questions …. Only after 4 weeks were we able to make some gains in terms of participation in discussion. What has worked for others?

    The other question that comes to mind is faculty development – should we be adapting the methods of debriefing we are teaching to national culture, or should we expect learners to adjust their norms and expectations to what we believe is the “best” method of teaching?!?!? Not sure what the answer is …. Can anyone help…
    Thanks again for the stimulating discussion

    Adam

  • Ian Summers

    Hello Ben and others,
    A late and brief comment.
    One style I adopt with hierarchy gradient across junior students and “cross culture respect hierarchies” is to at least state my own expectation. It goes like this and its framed in a conversational style and with a smile.: “I’m going give you my opinion. Its based on my expertise and experience but it’s also about what I observe about you, and you are a far greater expert on you than I am. So I want you to be able to disagree with me. In fact, I quite enjoy it. Tell me when you have an opinion that’s different to mine. Tell me about your thinking so I can understand it.”

    The first time anyone in the group does agree with you, encourage it. Live it. Then it no longer becomes disrespectful (or at least I hope it doesn’t) to disagree. I believe this approach works , but I have the partial insight to realise that it might not work from the viewpoint of another culture so I would love to have a stereotype or descriptive approach to what works (or what might work considering individual variations) on each group. Impossible?

    This from an anglo-saxon culturally bland Aussie boy. My guess is that Australian hierarchies are flatter. We are called by our first names. The humour that Vic alludes to (good natured teasing) is such a rich part of Australian and British humour and friendship and workplaces and we use it sometimes to soften the psychological impact of our words. To my mind that would be the most dangerous part of crossing into more respectful societies when our words might be taken more literally.

    Thanks Ben and the simulcast team as always. Any insights into this issue immensely valuable.

    Ian

    ps the answer to your problem in Paradise is just to keep eating, no?

  • Peter Dieckmann

    Thanks, Ben, and all for the invitation to take part in this discussion. Disclosure: I am one of the authors in the study.

    Hah – already so much “culture” in this sentence. The disclosure thing…(a more and more sensless ritual). The thank you thing… (a ritual to open conversations).

    I think the value of thinking about culture lies in stepping back, looking from a new angle onto our own position, our own standpoint. By comparing, what we take for granted with what the other takes for granted can generate new insights. Question is: do we then also adapt your actions (a question you raise, Ben, in one of your comments: would you do something different?). It requires openness about ones own ways of thinking, feeling (yes, we do have feelings), about our norms, values, and beliefs. It also requires to be able to distinguish understanding from judging – part of what Jessica Mesman from Maastricht calles “passivity competence”. Listen, observing, thinking, before responding. Seeing the situation from the standpoint of the others – us much as possible. Some of them, we might simply not be able to reach. It might be too different from my own standpoint to be possible for me to go there. I can think of many people I see daily in the news, whos standpoint are too far for me to reach (and I do not want to reach them – uuuups: Peter distinguish analysis from judgment!). Culture gets engrained – it is not only a way of seeing the world. It is a way of being in the world. Even bodily aspects (think of beauty ideals).

    Culture unfolds in so many different context. It is one of those concepts, that seem to be reasonably clear, until you read the first definition. Down it goes, the intuitive understanding. The more your read, the more you think about measurements, the more tricky it gets.

    Especially with globalization, the national culture becomes more tricky. I learned that, in running workshops on culture, where we asked people to represent their countrypeople (not -men: I live in Scandinavia, we are far with the gender issues! – Is this along the lines of Australian humor – get my “u” back it in that word, you damn yankee computer software autocorrection! Or do I get it wrong as principally humor (u!) less German)? Anyway: I asked this nice guy from the UK: Can you role play the stereotypical Brit? He looked at me like: “What? There is not such thing (a person) like this…They / we are from all over the place!” Point taken. So, likely the culture variety within a country is much larger than the variety between countries (imagine a German with humor (u!) – an American, who spells the Fxxx word with all letters – A Dane, who does not drink beer, go on, go on, go on). Departmental culture(s), professional cultures, morning shift cultures, night shift cultures, Christmans (ups – sorry seasonal greetings) shift cultures. Feedback culture…

    Might be interesting to explore that one.

    Imagine sports teams would have the same feedback cultures as healthcare. Just a moment. Get the picture? Not many goals in sight, my wild guess. That brings me to “assessing” cultures. Well, we do, right? All the time….Those xxx, ts, ts – always like that. They never [clean the table; say good morning] and always…So there is judgment in our cultural understanding and no matter how much we try, it will leak. So, somehow, we will assess cultural norms and will base our actions on this assessment (a good argument for bringing more ethics into simulation and healthcare as such). Question is from which standpoint? If we ask the high-hiarchy-position people, they might be quite happy. The others might not. The more I think about it, the more I think: the relevant standpoint for the assessment is: is this good for Esther (just learned that from some Swedes: Don’t say „good for ‚the patient‘“ but give his patient a name: „Esther“. Does make a difference, doesn’t it?). …Anyway, for me to find the guidance in how we should balance different cultures, the question of what is good for Esther makes a lot of sense. BUT: The Esthers in different cultures will think differently about what “good” means: absences of disease? Happiness? Go on, go on, go on.

    We are currently working with a multicultural team on looking at the hypotheses that we postulated in the paper that is up for discussion. Guess what: we could find empirical differences between cultures with different power distance and the way that debriefers describe their debriefings. The details I do not want to give away here – cross your fingers that the reviewers share your enthusiasm for the topic and accept that there are some methodological challenges. So, there seems to be something there.

    In summary – especially in those days of heated debates going on in the UN: there are differences. We kind of begin to get an understanding of them – although that easily goes away as well again. We can then begin to think about what we want to do with the those differences – level them out? Nurture them? Combine them? In some cultures Esther will benefit from advocacies and inquiry that her care givers sit through. In other countries Esther might benefit from another demonstration, of how it should be done right. No words needed. My own standpoint, when running faculty development courses around the world: I have a was that works reasonably well, where I come from. I would like you to take the time to understand it. Then I would like to think with you: how can we adapt this, so that it might fit your context. Or better: I want to help you to develop a way that will work for you. If that way, has a few elements of my way in it. Great. If not, I hopefully have helped you anyway see your way – and even, if you only you found out that my way is not your way.

    Peter

  • Shaghi Shaghaghi

    Thanks Ben for choosing such an interesting but complex subject. I found the article enlightening because of the cultural notions it presented. It made me realize how little I actually know about various cultures and their impact on the discussions we can have and the values we are supposed to “share and change”.

    I am from a middle eastern background, but grew up in French Canada. My middle eastern background has some of the same values as Nemat’s. We also practise another form of mitigated speech, where politeness and utmost respect is shown, especially to our elders, teachers and seniors and where it is important to make sure no one “loses face.” I had assumed I had more of a “western” upbringing and hadn’t given much thought about how my Middle Eastern background could affect my discussions in debriefing. I assumed this until recently when I was told by my simulation mentor, a very experienced, talented and somewhat senior facilitator, that there was an imbalance in our debriefing the debriefer sessions. Unfortunately, I am more of a taker than a giver. Basically, I didn’t have much constructive comments about her debriefing skills. After reading this article, I have been pondering on the reasons why I haven’t been able to “give back.” Could it just be that her approach is flawless, or maybe I just don’t have enough of a critical mind? Or is it that I haven’t been aware of the impact of my cultural background and that deferring to a mentor, a senior and a potential figure of “authority” are still things I unknowingly do? Maybe it’s a bit of everything.

    I also find that language changes a lot about debriefing. My primary language is French, but I considered myself bilingual until I started debriefing in English! My translated French and conversational technics don’t hit home like I would like them to.

    This article made me realize that we all bring a bit of cultural baggage with us when we interact, communicate, discuss and teach. Be it humour, respect for hierarchy or even language. I think we just have to be more aware of how our culture affects our frames and understand that others are also influenced by their own. I believe this will help towards creating the trust and psychological safety that we seek.

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