Simulcast Journal Club September 2017 – Trouble in Paradise

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

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  Victoria Brazil September 3, 2017 at 12:10 pm

  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

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  Nemat Alsaba September 8, 2017 at 7:51 pm

  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 September 9, 2017 at 3:44 pm

    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.

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  Mary Fey September 13, 2017 at 12:18 am

  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…..

  • 

    Ben Symon September 13, 2017 at 11:49 am

    Thanks so much for joining us Mary, can I ask how you would handle that situation differently now?

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  Adam Cheng September 15, 2017 at 9:46 am

  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

  • 

    Ben Symon September 17, 2017 at 7:30 pm

    Adam can I ask did you get any useful feedback from your Chinese candidates? Did they find the more reflective discussions useful?

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  Ian Summers September 20, 2017 at 9:12 pm

  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?

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  Peter Dieckmann September 22, 2017 at 6:15 am

  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

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  Shaghi Shaghaghi September 25, 2017 at 8:42 am

  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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  Ayidah Alqarni October 1, 2017 at 7:25 pm

  Hi Ben, thanks for inviting me. My Background I am from Saudi Arabia ABha Asia region south of Saudi Arabia I have had experienced as RN in Adult ICUs, as well involved in teaching as clinical instructor in ICU both gender and teaching in females nursing college. I came to Australia in 2009 I have had achieved few qualifications since. I am PhD student and it’s my last six month. In my project involve Simulation designs.

  The topic was interesting as my culture background Saudi as unic culture to study also we speak Arabic as first language.
  We experienced lots of challenges such as language barriers, different education background for nurses, gender issues. We experienced shortage of local nurses as like other countries. However Saudi government implemented program called Saudization outcome of this program to reduced recurritment expatriates nurses and increased local nurses 9% 1996 to 61%2015.
  We ended up with young inexperienced nurses workforce.
  Back to the point of this discussion as it’s captured me and I would like to share my personal experiences. When I was back home I teach few students in ICU male and female interns sometimes third year undergraduate students. Our culture segregation both gender in work place except critical areas. Some colleagues they have different views why I have teach male student I have to teach only female, as I mentioned early language barriers when I teach student I have to explained in both language that’s why student feel comfortable and confident when CI be local nurses. Sometimes people work in administration comment and try to stop me of teaching, you have to had strong personality and fight for your right as my father wisdom you have to challenges and barriers to be a nurse as back to 15 to 20 years society not accepted their daughter to work as nurse and classificed girls who joint nursing field as low class.
  But I have strong support from dad but not rest of my family and I a pproved them they are wrong.
  I had lots of challenges in my career but make me stronger every day.
  When I moved to teaching in female college back to 2003 numbers of students increased unfortunately we had shortage of local clinical education, we had occupied lab with different manikins we teach different procedures and skills in English but we couldn’t used Simulation as part of teaching specifically debriefing session but we provide feedback to student, even though its challenges to give feed back in English language as majority of students don’t speak fluent English. However we encourage student to read and practice conversations with English. Even in hospital received handreds of students both genders with different educational backgrounds it’s challenging expatriate nurses who are working in educational departments.
  I involved in teaching university of Adelaide PBL I found it challenging involved in debriefing sessions as well evaluated students.
  When compared International students to Australian students challenges me. In discussion part found 100% involved in discussion Australian student while international they didn’t involved much in discussion the reasons I think the methods of teaching bit differents as Here in Australia student depend in themselves use searching method read before class,while Middle East countries and Asia efforts on teacher providing “gold spoon” as we called it and student depend on the notes provide from teacher or CI

  From culture to culture it’s challenging to provide debriefing but I guess it’s good experience for me to learn from experience people around me
  Thanks Ben for this opportunity to shared my experience with you guys

  Part of my project designing scenarios as

• 

  Bishan Rajapakse October 1, 2017 at 11:19 pm

  Thanks to Ben for putting up this article for discussion, and to other for their contributions.

  I really found both the article and all the discussion fascinating. Sorry for being so late in the game with my contribution – this was largely because I have the Australasian College of Emergency Medicine (ACEM) fellowship OSCE exam around the corner – i.e. very busy times.

  However, perhaps being currently embedded in the training can provide another angle to the discussion? – after all, simulation based assessments are a now a big part of the way Emergency Medicine training is delivered (in Australasia).

  When I read this paper, I felt its brilliant theme was highlighted in the following paragraph;-

  “All studies of debriefing cited stem from Western cultures and may thus generalize only partly to other cultures. Many of the approaches may be more difficult for trainees who come from cultures where the motivation to defer to authority outweighs the choice to disclose views that may seem to contradict those of the instructor. What is seen as good communication in a Western culture might be different from what is seen as good communication in a non-Western culture. Moreover, the way to communicate about communication is likely very different.”

  I believe two make this paper particular relevant to training in EM ;-

  1) “quality debrief” is perhaps the key to making the most of this modality, and

  2) the levels of cultural diversity in Australasian Emergency Departments (in terms of ACEM trainees, ED staff in general, and the patients and families whom we care for.

  “Cultural identity?”

  Perhaps any reflection/discussion about the impact of “culture” should perhaps start with a discussion of what is culture and which culture one identifies with as a reference point. ( when looking for a quick online definition I found this fascinating article https://www.livescience.com/21478-what-is-culture-definition-of-culture.html )

  Like a few people who contributed in the discussion here, my cultural heritage is complex, as I grew up living in 3 countries;-

  I was born in Sri Lanka, but left when I was 6 months old and spend the next 6 years in UK, followed by 6 years in Saudi Arabia (primary and junior high school), and New Zealand (high school and university). I became a New Zealand citizen at age 16, however, I returned to Sri Lanka at age 31 and it was only then that I learned to speak my ‘mother tongue’, Sinhalese, and learned many other things about my cultural background.

  I’m consequently more of what is known as “third culture kid” ( – a grey zone between the culture one grows up in and the culture where one is from”

  ). However, despite spending most of my life outside Sri Lanka, it is perhaps one of the places I’ve felt most at home, even before I learned to speak it’s most major language. I also believe this affiliation is largely because of a multitude of subconscious cultural traits that I carry with me despite having grown up in other places. (I realise that this viewpoint is varies a lot amongst other Sri Lankan immigrants to different countries).

  “Reflections from doing simulation research/fieldwork”

  Whilst living in Sri Lanka from 2006 – 2010 doing research fieldwork I had the privilege of teaching many medical students, and junior doctors aspects of medicine, I was stuck by both the similarities and equally apparent differences in the way that people communicated and understood – I guess these differences were largely related to “culture”. Everyday I observed fascinating things – such as the incredible respect (and sometimes fear) that medical students in Sri Lanka, and junior doctors had for their seniors. For example sometimes when the consultant of a peripheral hospital where I conducted research would walk in the ward, everyone would stand out of respect. I found this at the times to be deeply inspiring (https://bishansworld.files.wordpress.com/2015/05/fig2.jpg ), and other times to be uncomfortable.

  Conversations about culture are so difficult, but so important (as many in the discussion have implied or stated). I believe the difficulty comes when we subconsciously affiliate or identify with a certain culture – and then any comment about this culture could become sensitive. The reasons it is perhaps sensitive is that often times we cannot easily change unconscious habit -even if we wanted to.

  When I returned to Australasia, and moved from New Zealand to Australia – to resume my mainstream Emergency training that I realised just how much my own behaviour was perhaps influenced by my own collection of cultural habits (sometimes operating quite subconsciously).

  I really can see some of the disciplines elaborated upon in the article, such as “Power distance – a measure of personal power or influence between superior and subordinate, as perceived by the subordinate”, are operating within myself in my medical interactions – particularly when taking to consultants, or perhaps when junior doctors are talking to myself, or when interacting with a teacher.

  One of the most fundamental aspects of communication in Emergency Medicine is dealing with other speciality teams, and also working within hierarchical teams within our speciality. I believe that given that many of us are working and/or training in increasingly culturally diverse environments, it would really benefit entire medical communities to educate ourselves about concepts like “power distance”, research further how such factors are influencing / impairing / or enhancing communication and debrief, both in the Sim world, and in the clinical world at large.

  I wonder if deep down, everyone wants to perhaps “be themselves” and perhaps “be understood” for what they intend to communicate, rather than what they have been interpreted as communicating ( as judged through various different cultural lenses).

  If this does in fact happens, isn’t it better to understand something about the multitude of lenses that perhaps exist?

  This article is a step forward in the direction of that understanding – Kudos to the authors! (and lovely to read the comments of one of the authors in the discussion)

  Great article 🙂

  thank you
  Bishan

  PS- Sorry to bore you with bits of my personal story – I couldn’t think of any other way to provide the necessary context to what I’ve written
  – And I’m so sorry my contribution was so late!
  ( – i did write to Ben before , and he said you are putting too much pressure on yourself to create a perfect response – just write something from the heart and do it quick!” – the thing is that I was very shy about what I was writing – I perhaps some of this shyness was also related to culturally influenced subconscious beliefs such as “power distance” )
  PPS- I do hope that this discussion page stays open – and the discussion continues? Such a fascinating topic…

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