Simulcast Journal Club July 2018 – Relationship Strain

Introduction :  

Simulcast Journal Club is a monthly series that aims to encourage simulation educators to explore and learn from publications on Healthcare Simulation Education.  Inspired by the ALiEM MEdIC Series, 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 in pdf and podcast format, including opinions of experts from the field. 

In order for the journal club to thrive we need your comments!  Some participants report feeling nervous about their initial posts, but we work hard at ensuring this is a safe online space where your thoughts are valued and appreciated.  To ensure this, all posts are reviewed prior to posting.  We look forward to learning from you. 

Copy of Journal Club (4)

Title :  “Relationship Strain 

It was a conversation that Nimali had been avoiding but coming home to a filthy kitchen and a frying pan full of cold, day old rice had pushed her conflict avoidance tendencies out the window.  She strode resentfully down the hall to find Joe and her son cuddled up on the couch.  Her husband cheerfully raised his glass in a casual welcoming gesture and turned back to his phone. 

“I’d like to talk about what’s going on in the kitchen.” She said icily.  “Is an ounce of cleaning too much to ask when you’ve had the whole day off with the kids?” 

“Not now mate.” sighed Joe.  “I’m tuckered out.  This one had me up since 4am.” He patted their son as he lay half asleep in his lap. 

“I think that’s a bit dismissive.” countered Nimali.  “We’ve had this fight a number of times and it’s a real trigger for me.  The dynamic seems to be that I ask you to step up and then nothing has changed.  I’m working full time again now, I need you to pull your weight!”. 

“It’s not my fault I got retrenched, Nimali.” Joe scowled.  “And it’s not lazy of me to leave some housework till after he gets to bed.”.   

Nimali sighed and sat down next to him on the couch.  She reached over and took the wine glass from his hands.  “I get it, hun.  I do.  I know it’s been hard finding new work, especially when you loved that team so much.  And I’m sure it’s not uncommon for men to struggle with their identity a bit after losing work. But I’ve taken on more hours to support this family.  If we’re really honest you’re being a great Dad but I’m still doing most of the housework on weekends, and when you don’t follow through, it makes me feel like you don’t respect how hard I’m working to keep us afloat.” 

Joe didn’t answer at first, but Nimali let the silence hang.  Calmly, without any anger, she held his gaze. 

A few more seconds passed, and then he leaned impulsively forwards in the couch and kissed her on the cheek.  “I hear you.” He said.  “And I’m glad that we could have a discussion without any damn debriefing techniques for once.”. 

Nimali smiled. 

The Article : 

J. Grant, T. Robinson, H. Catena, W.Eppich& A. Cheng (2018): Difficult debriefing situations: A toolbox for simulation educators, Medical Teacher, DOI: 10.1080/0142159X.2018.1468558 

Discussion :  

In the case study today, Nimali faced a reluctant, dismissive encounter at home.  While she and many of us may feel we have mastered the basics of debriefing, most of us could name similar times in our lives when a conversation was uncomfortable or difficult.  In this open access paper by Grant et al, the authors provide us with a list of common debriefing conundrums while simultaneously providing useful verbal and non verbal techniques to approach them. 


For our bloggers this month, what did you think of the paper?  Do you think it will help your practice?   Are there any challenges you experience commonly? 


References : 

J. Grant, T. Robinson, H. Catena, W.Eppich& A. Cheng (2018): Difficult debriefing situations: A toolbox for simulation educators, Medical Teacher, DOI: 10.1080/0142159X.2018.1468558 

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.

16 thoughts on “Simulcast Journal Club July 2018 – Relationship Strain

  • Mary Fey

    Hi Ben,
    As I was reading this, I was thinking “It doesn’t matter how long I’ve been a debriefer, when things get uncomfortable, my first instinct is to get away from it!” As I read the story, it really struck me that Nimali’s key move was to sit down next to Joe and share his wine. She leaned into it, not away from it….

    What the Grant et al paper provides are practical strategies for “leaning in”; helpful to novice and experienced debriefers. The phenotypes they describe are all situations we’ve dealt with: disengagement, domination by one who has poor insight, domination by an expert, defensiveness, etc. I find the most helpful section of the paper to be the “toolbox”, in which the authors describe both proactive and reactive strategies. It’s been my experience that, with difficult debriefing situations, an ounce of prevention is worth a pound of cure. As my prebriefings have gotten better over the years, my debriefing difficulties have decreased proportionately.

    One element that I was longing to see in the paper was more discussion about building rapport with the learners prior to the simulation. As I see it, prebriefing is the time to convey to the learners that they can trust me. I do this by purposely building a relationship (or it can be thought of as building social capital). I discuss our shared norms: patient safety, wanting to be seen as expert clinicians, etc. I also connect on a personal level: kids, dogs, food, travel, etc. My goal is that they see me as a normal (and imperfect) person who wants what they want – to be a valued part of our community, to be striving to get better at this important job we do, and as someone who’s concerned about my professional identity (just like they are).

    The reactive strategies are real life savers! When that “Oh, no!” emotional reactions gets triggered in a debriefing, these are the tools you want to be able to pull out of your toolbox. Finally, the authors also acknowledge that not all problems can be fixed in debriefing. Just like our learners, we aren’t always going to be superstar debriefers. I remember one experience in which I unsuccessfully tried to draw a learner into the conversation who was withdrawn (in body language and verbally). When we got to the end of debriefing, and participants were describing what they’d learned, I asked that person what they’d learned. Their response? “Absolutely nothing”. You can’t win ’em all….

    Thanks again, Ben for tackling an important topic!

    • Ben Symon Post author

      Oh Mary Fey, I thought you really did want to hear about my dog! :p

      Thanks so much for your comments, I learned a number of things from your statements.
      Firstly, the importance of rapport building through shared experiences as a way of building social capital that can be cashed in later in exchange for the permission to be honest.
      Secondly, the acknowledgement that we can’t win ’em all, and that not every conversation can be transformed into a life changing debrief :p
      Thirdly, that with time comes experience, and that pre-emptive strategies in combination with skilled facilitation prevent a significant amount of defensive learner behaviours.
      I always appreciate tapping into your wisdom and experience.

  • Eve

    Hi Ben,

    Thanks for this interesting scenario and good paper.

    In particular, I liked that the authors supply language and phrases to employ. The ones that I found most helpful and am most likely to give a go are naming the dynamic, and previewing. Of course the scripts given will be massaged into more natural language of my own but I think an awareness of these approaches will be useful.

    I found Figure 2 (cognitive aid for combining reactive strategies) to be a bit of a stretch and in fact cognitively overloading. I think the point is that you can combine strategies, which is fair, but I worry that this prescriptive approach may overwhelm some debriefers who get overstressed about applying the strategies in the sequence offered.

    I found Joe’s suggestion that Nimali didn’t use any debriefing strategies (even though she did, quite effectively) to be a bit comical – and reminds me that the expert educators that I work with and learn from every day make it look easy…


    • Ben Symon Post author

      Hi Eve! Was great to meet you the other night, and thanks so much for coming along.
      I’d kind of vagued out when looking at Figure 2 as well. I appreciate that a lot of thought has gone into it, but to me it is a bit of a contrast to the rest of the paper (Which is so nicely streamlined and accessible while also having remarkable depth).
      I’m curious about how that specific tool was developed, as there’s clearly a lot of work involved in its development.
      Why was it that previewing and naming the dynamic stuck out for you so much?

      • Farrukh

        Love your story example / you should do some short story writing also Ben 😉

        I agree with Eve about the comical nature of the interaction with Joe and Nimali and also with Rebecca about starting off using A/I and how it can come off as robotic sometimes. I remember after my first CMS course, trying hard to use A/I at home.. just to make it more natural. It did make it tough with my toddler…

        I observed that you pooped in the tub again. That makes me uncomfortable as it is not sanitary, we have to re-rinse you and clean the tub and that also cuts into story time before bed. What’s up with that?”

        But just like Nimali and Joe, this paper along with the advanced CMS course, there are so many tools that I found I can begin to utilize during my debriefs. The A/I is a great start point but these dynamics will eventually show up. It is labelled as “difficult debriefing,” but to be honest, I find one of these happens in each debrief.

        The mannequin is not real enough
        I cant believe I shocked asystole
        The parent was too involved and needed to be out of the room
        This is not how it would have gone in the real world

        These tools are great to be able to redirect into a learning platform. I often wonder also, how a PEARLS cognitive aide was created, if something along the line exists for these debreifing tools to offset some of the cognitive load on nascent debriefers such as myself?

        I love the name the dynamic. When a very tough situation comes about, to avoid, as Mary pointed out, is natural. But to name that elephant in the room is so powerful.

        Another great read, thanks Ben!

        • Ben Symon Post author

          Hey Farrukh, thanks for coming along again, you cracked me up with your toddler A/I analogy!
          I was interested actually that you mentioned the PEARLS cognitive aide with respect to this article. I noticed that the colours chosen by the authors for their images in Figure 1 and 2, (the ‘Difficult Debriefing Tool’ and the ‘Applying Strategies for Difficult Debriefings’) were the same as used in the PEARLS tool. Is this just habit, or is the goal that these tools be used together as a little suite?

  • Rebecca Smith

    Hi Ben,

    I loved this paper. I’ve had plenty of simulation experience as a learner during my training but now find myself on the other side, learning the art of the debrief. I have stumbled my way through Advocacy Enquiry and have subsequently found myself in many a difficult debriefing scenario. The experts make it look so easy. My ‘go to’ strategy has always been to take a co-facilitator with me to share my pain and help bail me out if it all goes pear shaped.

    What I loved about this paper is that it not only reminded me of the importance of not making assumptions of our learners but gave some really practical strategies to help both identify the cause and then manage challenging situations. I especially loved that the examples given were in a language that felt natural to me. I feel that a lot of my difficult situations have actually resulted from me trying to use a more formalised approach (such as Advocacy Enquiry) with language that is not my own. Sometimes I hear the words coming from my mouth and wonder if some foreign entity has taken over my brain. As I have become more comfortable with debriefing I’ve come to realise that my best debriefs happen when it’s just me having an engaged conversation with the learners rather than me focussing on identifying problems and then rigidly applying educational techniques to unpack them. I think the toolbox offered by this paper will give me the confidence to push a little harder to really understand my learners. Tackling ‘the elephant in the room’ is daunting when you are a beginner and it’s often tempting to avoid uncomfortable conversations for fear of eliciting a strong emotional response or causing harm to your learners. I’ll still be taking my co-facilitator with me but I’m looking forward to trying some of these strategies and pushing myself as a debriefer.

    This will be a paper that I re-read often. Thank you for bringing it to my attention.

    • Ben Symon Post author

      Thanks for sharing your thoughts Rebecca! I agree this will be a paper to re-read often and reflect upon after a difficult debrief. Looking forward to seeing you soon!

  • Susan Eller

    Hello Ben,

    I am definitely having “frequency – illusion” phenomenon about naming the dynamic. I think because it was a tactic that I did not use very often in debriefing, and after learning in our AIC that I could say “wow, that was harsh”, I now have a profound respect for using that technique when merited.

    I found the article a good resource for many techniques for difficult debriefing. Like Mary, I wish the authors had more space in their article to include some of their pre-briefing strategies; as that group of experts no doubt has some powerful examples.

    I can see how the cognitive aid in Figure 2 could seem like a cognitive load challenge. I guess when I was reading the article, the suggestions in Figure 1 seemed mostly familiar, so it was a good challenge for me to see how they were combining strategies in Figure 2.

    I found the learner follow up section interesting, and have had situations where I do try to sort things out with someone after a difficult debriefing. And – I also agree that you can’t win them all.

    Cheers – Susan

    • Ben Symon Post author

      Hi Susan, thanks for joining us.
      I was interested that you would have liked more detail in the prebriefing strategies, in that I had a different response which was ‘there’s already a good article on that in the safe container, so I’m glad they budgeted more words for these different tools.’. Were there specifics about pre-briefing that you would have liked to hear more about?
      I had kind of overlooked the learner follow up section after reading this article the first time, and I’m so glad you point it out, because it’s such an important strategy that’s easy to forget about.
      Hope all is well!

      • Susan Eller

        Hello Ben,

        Thank you for asking the question, as it caused me to reflect. I will have to re-read the article on the safe container to review that discussion

        You mentioned Walter’s talk on our own mindfulness and triggers, and the answer that bubbled up when you asked me about pre-briefing specifics was actually: “listening”.

        Similar to Mary’s point about developing rapport – I found that one of the things I needed to do in pre-brief to avoid challenging debriefing sessions was to listen to participants concerns or experiences with simulation. To be mindful, but not focused, on their experiences or triggers regarding simulation. Not to give it all the attention, but to acknowledge if some of them had less than ideal memories from nursing school or other venues. It helped me tailor my safe environment discussion by focusing on what we would be doing – not saying “I won’t do that bad thing someone else did”.

        I have had enough discussions with simulation educators, that I know there are those with good and bad experiences, and I try (at least somewhat) to understand the place where the learner is coming from in order to co-create an environment to maximize learning.

        Okay – maybe too much reflection for one night, but I appreciate you triggering my thought process.


  • Ben Symon Post author

    I obviously loved this article, having chosen it for this month, and I think it’s pretty much an instant classic that I hope will be considered ‘foundational reading’ quite rapidly in any sim curriculum. When I spoke to Vincent Grant about us featuring the paper, he mentioned the paper being ’10 years of distilled experience’, and I hope he won’t mind me quoting him there, but I think it sums up the paper beautifully. Advanced strategies and experiences presented in a streamlined, efficient, approachable paper that will hopefully translate well into clinical practice for those less used to the tools outlined.

    In terms of critique, apart from agreeing with Eve that Figure 2 is a little complex for me personally, one thing that really effected my response to the paper was actually hearing Walter Eppich talk recently about these principles. One thing he highlighted beautifully in his lecture was the importance of mindfulness and being aware of what we bring to the table as debriefers (in terms of our own prejudices, triggers etc). My take home from his talk was that in some difficult debriefing situations, we may be actively contributing to that difficulty, and as such an important part of becoming an expert debriefer is understanding ourselves.

    So I had kind of hoped (probably unrealistically) to hear some of that in this paper, especially after noting that the title for the paper was ‘difficult debriefing situations’, which to me seemed very carefully chosen to avoid labelling anyone as a ‘difficult debriefing participant’. But as I created the Infographic for the paper, I realised that all of the examples were still about difficult learner behaviours. The shy one, the bossy one, the bossy one who actually knows what they’re doing, etc. I think for such a foundational paper that’s appropriate, and this paper covers so much so well, but one day I hope to read the more mysterious, mirror image of this paper, about how the judgments, pre-conceptions and behaviours we bring as debriefers effects those in the debrief too.

    • Victoria Brazil

      Thanks Ben and to everyone who has been part of the chat so far.
      Agree – a great read – and summarises and connects some strategies and concepts I’ve used more haphazardly for a while.
      As with my reading of many debriefing papers, I still feel a tension between offering principles and advice, while avoiding recipe driven reactions eg if you see ‘x’ then do ‘y’. So perhaps like Eve and others suggest – i can’t see myself using Figure 2, but i like being able to name the described strategies as the authors do – in part for myself and also when i work with a team of who often co-debrief we can keep track/follow others ‘moves’.

      When i read this kind of paper i feel its such a shame there is not more multimedia in ‘traditional’ journals/ publishing – the examples related to silence, eye contact, body language and voice intonation when saying those phrases would really come to life if we saw them in action.

      And yes – there is another who paper on ‘difficult debriefers’ – which i suspect we all are at some point, label or not !

      Thanks again Ben

    • Vince Grant

      Thanks again Ben for choosing this article for discussion on Simulation Podcast and for all of the insightful and humorous comments made by everyone so far. I apologize for not being able to join the conversation sooner, but I have been away with my family on vacation trying to precariously balance my desire to stay connected to the conversation and inadvertently creating my own “difficult debriefing” situation on the home front. I suspect the conversation in the Grant household might have been as entertaining as Ben’s take on Joe and Nimali or Farrukh’s difficult conversation with the tub invaders.

      All kidding aside, I am so pleased to hear how this article has touched so many educators. As Ben mentions, these are all ideas based on experiences that we have collectively shared over the past 15+ years, and found useful as ways of navigating difficult situations. We actually teach the use of these tools in our advanced faculty development courses using trigger videos and role-play for our simulation faculty.

      I thought I would respond to a couple of the specific comments shared in the journal club, although I will try to brief so the post doesn’t end up reading like a novella…

      First off, I really loved Mary’s comments about “leaning in”. We really hoped that this toolbox would encourage debriefers to be able to do just that when they face difficult situations. I now think we should have titled the article: Difficult Debriefing Situations: A Guide to Leaning In. Thanks Mary! I also really appreciated Mary’s comments about building rapport and the value of creating and maintaining a safe environment for learning both before and during the simulation event. I would totally agree that our evolving expertise with prebriefing has avoided many more difficult debriefing situations. However, they still do occur (“you can’t win ‘em all indeed!) and we wanted to offer some practical suggestions to the community of practice when they unfortunately do occur. We also felt that the topic of prebriefing was so well covered in other venues, that it did not need to be re-captured in this article . . . and we also needed to save valuable space for the rest of the difficult debriefing conversation.

      I also really appreciated all of the comments about Figure 2. To be perfectly honest, we really struggled with Figure 2 and how to present the idea that the tools could be used in a sequential fashion to manage difficult debriefing situations when initial attempts at using a specific tool alone didn’t seem to work. We were quite worried about whether or not the suggestions would come across as too prescriptive, as the debriefing conversation (or any conversation for that manner) is dynamic and doesn’t lend itself to a prescribed menu of options when you as an individual are only one half of the equation. We were hoping that the readers would simply see them as suggestions and that the sequential use of tools could be used in any order. I apologize for the increased cognitive load that we may have caused some of the readers. You should have seen the cognitive overload trying to come up with the Figure… In terms of the color scheme for the cognitive aides, I guess it is safe to say that Adam’s favorite color must be blue. I also think it is safe to say that they are meant to be used in parallel.

      Next, I want to touch on the comments about co-debriefing / co-facilitation. Thanks to Rebecca for bringing this up. Co-debriefing is a strategy that we also use to help with the identification, avoidance (hopefully) and management (sharing the pain indeed!) of difficult debriefing situations. In fact, in our program, we have mandated (maybe strongly suggested) that all sessions require a co-facilitator. Adam Cheng (and a few of us) published an article a few years ago on this very topic. The interesting thing about our experience with co-debriefing is that the co-debriefing dynamic can itself sometimes cause difficult debriefing situations. We have some more tools to share about Difficult Co-Debriefing Situations, so keep your eyes open for that one down the road.

      I also wanted to comment on Rebecca’s comment that a formalized structure sometimes doesn’t come across as natural, “with language that is not my own”. We couldn’t agree more. I am so glad that you found the examples and language in this article something that you (and all readers) can take away and personalize for yourself. We are big believers in having a natural conversation, and wanted to make these tools accessible in that regard. Although we still advocate for some structure in the debriefing conversation, we really want our debriefers to develop their own natural style using the phases, methods and tools that we teach. We have seen many great examples of this in our own educators, and have confidence that you (and other readers) will do the same. Good luck!

      I really appreciated Susan’s (and Ben’s) identification of the importance of learner follow-up. Above all other elements, I have found this tool of increasing value over the years. Having the comfort and confidence to let things sit with a learner for a while can lead to some really valuable insight and more engaging and influential conversation later on. I have had really emotional learners go on to understand and appreciate the value of simulation and the emotional realism that simulation can have for learning groups. I have also had very defensive learners identify the problem with their assumptions and their choice of delivery in the debriefing, among many others. Sometimes, not everything can be resolved in the 20-30 minutes that we typically devote to a post-simulation debriefing, so this tool can be very helpful to let further self-reflection happen (as much on the educator end as the learner end), to let some of the strong emotions dissipate as a means to being more open to a two-way dialogue, and as a way of re-connecting ourselves to each other (since feedback does lie at the sometimes painful intersection of our desire to improve and our desire to belong).

      I was really interested in Ben’s comments about the problems that the debriefer / facilitator brings to the table. I would totally agree that the entire debriefing equation includes: 1) the educator (or co-educators as alluded to), 2) the content / message and 3) the learner, and that we were really only able to focus on the learner in this article. To be honest, we had hoped to write on all three, but were forced to trim things down for ‘publication’. We thought the toolbox of skills was most essential for novice and experienced debriefers alike as they experience difficult debriefing situations. The next step of ‘Jedi’ debriefing training definitely involves some mindfulness (and self-regulation) of what we as debriefers contribute to these difficult situations. As you suggest, there are a lot of great ideas out there . . . Walter Eppich is a master at highlighting these factors, so you have already heard from one of the best. My gut feeling is that the ‘mirror image’ that you speak of is something that we may hopefully read about really soon.

      Finally, I was really happy to see Vic chime in with some inspirational thoughts to bring these ideas to the next level. We have been thinking about this very problem for some time, and to further explore the idea of creating more multimedia for people to use in their evolving debriefing practice, especially with more advanced skills. As mentioned earlier, we are able to use video exercises and role-play in our simulation faculty development courses in Calgary to accomplish this objective locally, but we have long wanted to produce some examples that can be shared more globally through on-line portals like Debrief2Learn. Your suggestions have re-ignited that desire . . . we will endeavor to get some content out there soon.

      So, thanks again to Ben for choosing our article to review this month on Simulation Podcast, and for all the insightful comments and suggestions shared by the community. We do sincerely hope that all simulation educators will find these tools approachable and useful (other than Figure 2 . . . damn!). In many ways, we have merely opened Pandora’s box when it comes to difficult debriefing conversations and we look forward to hearing and learning more from others as they continue evolving on their journey as debriefers. Please let me know how we can help . . .

      Good luck everyone!

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