Simulcast Journal Club June 2019


Introduction :  

Simulcast Journal Club is a monthly series that 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.  Inspired by the ALiEM MEdIC series, 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. 

Title :  “All About Eve 

The Articles : 

Brazil, V., Purdy, E., Alexander, C. and Matulich, J. (2019). Improving the relational aspects of trauma care through translational simulation. Advances in Simulation, 4(1). 

Purdy, E. (2019). Simulation and Cultural Compression. [online] ICE Blog. Available at: https://icenetblog.royalcollege.ca/2019/03/19/simulation-and-cultural-compression/ [Accessed 29 May 2019]. 

Purdy, E., Alexander, C., Caughley, M., Bassett, S. and Brazil, V. (2019). Identifying and Transmitting the Culture of Emergency Medicine Through Simulation. AEM Education and Training, 3(2), pp.118-128. 

The Case :  

Nimali and Catherine sat together quietly on the outdoor balcony of their shared office.  They had been sipping their International Roast in the kind of comfortable silence that can only be achieved by a friendship forged in shared tribulations and time honoured secrets.  Catherine looked at Nimali with a touch of melancholy, and took a deep breath. 

“I need to tell you something Nimali. I’d been holding off for a while, but given the events that have happened in the last few hours, I figure my news won’t be too upsetting by comparison.”.  She sighed and paused. 

“My wife has been redeployed to Perth, and I don’t want the kids to have another 6 months without her in our lives…” she trailed off and wiped a tear from her eye.  “We need to pack soon.” 

She stared hard into her friend’s eyes.  

A brief look of grief passed across Nimali’s face and she paused and gazed out at the rain again.  It was a few minutes before she had regained her composure.  She reached across and held Catherine’s hand. 

“I’ll miss you too.  I’ll miss our chats on this balcony.  I’ll miss sipping wine with you and Tegan as our kids play together.  But you know what I’ll miss most of all?  The way you teach.”.  She laughed a little as memories bubbled to the surface of her mind. 

“I learned so much from you when I first started here.  Not just from the things you’d say or the workshops you’d run, but from the tone you set with your team on the floor and your learners in the classroom.  I don’t know how you do it, but I can tell when someone’s worked under you.  They have this sense of compassion for the patients and families in their care.  They don’t slur colleagues in the tea room.  They fight for sick kids to get the best treatment possible, whether they’ve got a Hypoplastic Left Heart, or they’re self harming or they have worried parents and a cold.”. 

She gave Catherine a half smile. 

“I think… It’s not something you say, or how you debrief…. Even though all those things help.  It’s something else, Catherine.”… Nimali paused again as she tried to find the words she was looking for.  There it was. 

“You teach them by being the best version of yourself.  Every day.” 

She held a hand gently to her friends cheek and softly kissed her forehead. 

“My god.  We’re going to miss you.” 

Discussion :  

How do we really transmit knowledge through Simulation?  Can we tell the actual learning from ‘take homes’, and debrief discussion points?  Or is there more going on here that’s much more subtle? 

In the last 6 months, Eve Purdy and her colleagues have published a number of articles and blog posts on insights gained from our favourite dual trained Anthropologist and Emergency Physician.  While we’ve discussed these with Eve herself on this month’s Simulcast podcast, it’s now time for you guys to read them and give us your take on the messages we’ve learned about Simulation and its relationship with cultural transmission and relational learning. 

We look forward to your reflections and comments. 

Yes, that’s right.  It’s 3 articles in one month. 

We believe in you. 

References : 

Brazil, V., Purdy, E., Alexander, C. and Matulich, J. (2019). Improving the relational aspects of trauma care through translational simulation. Advances in Simulation, 4(1). 

Purdy, E. (2019). Simulation and Cultural Compression. [online] ICE Blog. Available at: https://icenetblog.royalcollege.ca/2019/03/19/simulation-and-cultural-compression/ [Accessed 29 May 2019]. 

Purdy, E., Alexander, C., Caughley, M., Bassett, S. and Brazil, V. (2019). Identifying and Transmitting the Culture of Emergency Medicine Through Simulation. AEM Education and Training, 3(2), pp.118-128. 


About Ben Symon

Ben is a Paediatric Emergency Physician at The Prince Charles Hospital in Brisbane and a Simulation Educator at Lady Cilento Children's Hospital. He currently teaches on a variety of paediatric simulation based courses on paediatric resuscitation, trauma and CRM principles. Ben has a growing interest in encouraging clinical educators to be more familiar with simulation research.


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14 thoughts on “Simulcast Journal Club June 2019

  • Kris Phare

    I have no doubt that simulation is both beneficial from both cultural and learning/fact sharing perspectives.

    In my experience, performing regular high quality sims in an environment you are also working, with the regular members of the department/team – is invaluable. I think as they can facilitate the inherent cultural values of an environment (if done correctly), the fact transmitting aspect becomes more natural – people speak up, ask questions, provide constructive feedback. If this can happen between members of different departments then all the better too. It can be incredibly difficult working with a group of new people in a high octane/stressful setting for the first time, and sims provide an avenue to explore those group and inter-personal relationships as well as continue to build on them as time goes on. Further to that I think it’s easier to welcome new members into a well established culture, they settle in quicker, buy-in to the culture quicker, become an effective member of the team, cycle repeats. Interesting topic! Thanks for sharing.

    • Ben Symon Post author

      Thanks Kris! What I’ve taken from your post is that transmitting culture through sims can be an efficient method to welcome new members into a team, build relationships with them but also to role model expected behaviour. Have you had much Simulation happening in the GP setting?

      • Kris Phare

        Not so much in the GP setting sad to say. I suspect this is down primarily to the ‘time is money’ feeling in many practices, which is a little bit more palpable than in hospital settings (IMO). We do have a resus area with all the equipment here in this practice but no simulations as yet. Plenty of role-playing for history taking however! Which is a little less time and resource intensive.

    • Eve

      Hi Kris,

      Thanks for your thoughts! Your perspective around using simulation to help new people “fit in” is very much in keeping in what we found with the simulated emergency department that we ran with medical students. Simulation can act as a moment of “cultural compression” – a time where the signals around values and beliefs are particularly strong. This has benefits and drawbacks, but mostly means that we should probably understand that what happens in the simulation room with respect to cultural transmission may be amplified beyond our day to day work!

      Eve

  • Jenn Dale-Tam

    Simulation and culture have a symbiotic relationship where one shapes the other and vice versa. This becomes more evident, I find, if the clinician(s) that wrote the scenario and facilitate it are entrenched in the real environment they are trying to replicate. Explicit translation of culture in simulation happens through conscious role modeling of facilitators and senior members of a team during the scenario continuing into the debrief, especially if values or norms are written into the objectives. Implicit translation occurs through cues, communication and reactions of team members when behaving as the would in the clinical environment. Cultural translation, whether purposeful or not, can have negative and positive effects in the long term. In my experience simulation has a positive effect.

    Over the course of a 2 year period working with the same nurses, but various interprofessional teams with during in situ simulation I noticed the way junior nurses changed their behaviour interacting with senior members of the medical team. In the beginning they were reluctant and shy in the debriefs to express what they needed from the medical team in regards to clear communication and needs in a crisis situation for safe patient care. Through a purposeful strategy on my part during the debriefs role modeling effective communication and respect with senior medical personal the nurses became more forthcoming in the debriefs to the point that I barely had to facilitate. The conversations happened naturally between the interprofessional teams. It was a true pleasure to witness.

    Simulation is a powerful tool for cultural transmission in the healthcare environment.

    Thank you for this topic.

    • Ben Symon Post author

      Thanks Jenn, it’s always so lovely to have you with us here. I strongly agree with regards to the symbiotic nature of Simulation and Cultural Compression/Transmission. One thing i’ve noted in your comments is that you differentiate between intentional and unintentional use of Sim as an intervention for this process. I think what I love about this series of articles is that they highlight an awareness of these concepts that I do not think was being explictly, effectively described in Simulation Literature. It’s such an important aspect of what we do, but I find these articles have given me the words to describe that more effectively.

      In doing so, I think it also allows me to design with that intent in mind.

      One thing that does fascinate me though is how sometimes we create this weird parallel culture. People sense that behaviour expected in SIM is not the same as what is expected on the floor. The same people who speak up in a sim may still be quiet in real life, because the cues they’re getting are different, and they reflexively alter their behaviour in accordance to this. It sounds like your deliberate strategy of using sims to encourage nurses to contribute more to professional discussions, can I ask what your reflections are about how it translated to the clinical unit?

      • Eve

        Hi Jenn (and Ben),

        Thanks for reading and commenting!

        This year, being entrenched in thinking about simulation + culture, I agree with both the importance of implicit/explicit messaging. I think mindfulness of these goals as facilitators and participants will go a long way.

        I like your idea of actually including culture (values, beliefs and practices) into the potential learning objectives…in a way making the implicit explicit for those teaching and learning. Most cultural learning is implicit but value-signalling is also important! Even having a simulation program (and what that looks like) is a cultural signal itself….

        You are so very right in saying that there are a whole potential # of important factors that affect behaviour int he natural environment that do not necessarily come to play in the simulated environment. Sorting out the dose, and targets of a sim program to affect culture change might be the next step!

        Always happy to chat more.

        Eve

        • Jenn Dale-Tam

          Hi Eve,

          I could not agree with you more about value signalling as being important. I sign post the importance of having the patient as the center care for nurses. This became evident when I practiced as an ICU nurse looking after a very ill patient with multiple pressors, intubated, sedated and on continuous dialysis. I was so focused on the machines I forgot about the patient underneath all.On my next set of shifts I looked after the same patient who was much better, extubated and communicating with staff. He remembered my voice and told me how alone he felt while I was looking after him before, that he was not included in any of the care. This was an “ah-ha” moment for me in my career, from that day forward I always communicated with the patient first before providing care, even if they could not communicate back. Now as an educator I stress the importance of this through simulation and many times during the debrief my saying of “we are nursing patients not machines” comes up. Many healthcare professionals get tied up in the technical skills of their professions and forget about the patient underneath.

          I had not thought of it as culture at the time, but on reflection, have come to appreciate it as such.Thanks for bringing this forward.

      • Jenn Dale-Tam

        Hi Ben,

        I’ve seen junior nurses (<2 years) have more confidence to approach members of the inter-professional team, especially senior ones, early in the start of their careers since the implementation of our in-situ simulation program through purposeful role modeling in the debriefs. As a result, the junior nurses go directly to the care team when they have a concern or a need for their patients instead of through a senior nurse. This is also reciprocated from our surgical residents as well. Each have established their professional relationships early. In our daily discharge rounds the junior nurses have a strong voice for their patients. We are truly trying to establish a culture of inter-professionalism and in-situ simulation has helped transmit some of that.

        • Benjamin Symon

          Oh how fantastic to hear Jenn, how wonderful to see deliberate cultural interventions leading to visible outcomes in clinical practice. Living the dream!

  • Benjamin Symon

    I’d like to comment specifically on Eve’s blog post at icenet blog.

    A couple decades ago when I was about 18 I met my first boyfriend and we ventured to a local bar for a drink. Almost all of my memories of that night surround a sequence of events that occurred after we furtively held hands at our table in a corner of the room. Within minutes, a bouncer had arrived to stand with folded arms next to our table, making direct eye contact at both of us. He stood there for a period of time until we stopped hand holding, and then Trent quietly kissed me on the cheek. As he did so I looked across the room, and saw two women laughing at us as he did so. My memories of that quiet attempt at romance are primarily dominated by those two small events. Neither particularly harmful.

    Reflections of experiences like that came up vividly when I read these papers about the concept of cultural compression. As Eve describes, the concept of Cultural Compression is when “the norms of society bear in upon one with the greatest intensity.”. While this is proposed through an educational context, it was a clear description of a number of experiences I recall vividly throughout my life but didn’t necessarily contextualise within a sociological perspective. To shift those behaviours from negative individual experiences to an understanding of cultural norms at the time of the events is to me, a healing one, but also a revelation.

    I think for me that informs why this concept resonates so strongly for me within an educational concept. The messages we send each other when role playing in Sim, how we design our scenarios and the behaviours we role model throughout simulation in any context are powerful messages that our colleagues expertly adapt to.

    Wise words from Eve, and I’m very grateful for them.

    • Eve

      Thanks for sharing your story, Ben. I am glad that the term has been helpful in processing some stand out events. Shame that it happened. Your story for me highlights the point that it’s potentially hard to predict which small actions or decisions will have the biggest impact as they land (in sim and in life). I can almost guarantee that neither that bouncer or those girls remember their actions that night or the unfortunate lasting impact.

      Just like those idiots at the bar, we are bound to get it all wrong occasionally (though hopefully with less hurtful intent). It’s possible though that we can prevent some harm (and do some good) with mindfulness and reflexivity around cultural signalling in the process of designing/facilitating simulation. I think it is something that we owe our learners and our colleagues. I reckon (again in sim and in life) that kindness and generosity of spirit are the best way to stay out of trouble.

      • Ben Symon Post author

        Thanks Eve, No harm done and life is good, and isn’t it wonderful how much the world has changed. But to me it was just meant as an illustration of how I’ve contextualised your teaching and reflected on it rather than “woe is me’ing”. The lessons I’ve taken from your articles is that there is teaching and learning in every interaction we have, that culture exerts a powerful force on our behaviours and that naming that explicitly can help us actively shape the conversation rather than letting culture subconsciously effect our teaching.