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I.
Group dynamics
Debriefing multidisciplinary teams with clear demarcation of ‘hierarchy’ between physicians and nurses or attendings and residents makes it difficult for many to ‘speak up’ for fear of ‘losing face’ and ‘judgement’ and with multidisciplinary teams, non-clinical debriefers ‘avoid confrontation’ with participants on clinical knowledge such as discussing misdiagnoses or incorrect treatment. These perpetuate the notion that physicians are ‘infallible’, they carry ‘great expectations’. |
a. Hierarchy |
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i.
“I debrief in different countries--there are differences in the cultures/hierarchy plays a role--impact on atmosphere and how easy people talk. Italy: Loud! Hierarchy not so clear. South Tirol: you often have a big boss kind of in the background, like a shadow. Never really visible, but always present. (Germany, 35)
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ii.
“Where I work, there is a sizable number of migrants from Arabic countries. Arabic and Asian cultures have very steep hierarchical gradients. It's pointless to try and teach many of the people stemming from these Cultures things like “speaking up”, because it clashes with their understanding of respect. Debriefing people with such cultural backgrounds is very challenging to me.” (Germany, 35)
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iii.
“Yes, the extreme distance created by discrepancies of power and the significance of hierarchy. Ultimately, very little value is allocated to team concepts, as most stem from a generation of loners. Within a group a leader is chosen, and this leader's decisions will not be questioned.” (Switzerland, 34)
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iv.
“This has to do with the local circumstances of how leadership is structured and secondly with the ratio among the different professions (physicians, nurses, students, residents, attendings …). e.g. speak up. Going up the chain- it doesn't matter what you say people with higher hierarchical status are tone deaf to this topic. Hierarchies are steep. People will discuss “speaking up” with the peers at their level, but it's pointless to raise the issue with higher ups. The ratio of professions: e.g. Anaesthesia nurses and physicians. Among these two professions, the practical scope of their occupation is the same. But nurses are unable to speak because their professional background is very different. They will not speak up.” (Switzerland, 34)
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v.
Hierarchical. Would not speak before the boss; being asked first is a challenge for the participant being asked. You do not know yet what opinion will be acceptable and thus, might be reluctant to state it. Chief might intervene, then you have to stop them as soon as you can, typically each discussion stops in such a case.” (Romania, 90)
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vi.
“Challenging authority gradient within medical hierarchy is a foreign concept and not accepted culturally.” (Malaysia, 100)
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vii.
“Some hierarchical elements sometimes occur within the scenario e.g. paramedics may take over although out of their usual context however keep very quiet during debriefing.” (India, 77)
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b. Speaking Up |
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i.
“Simulation usually brings professionals together that don't know each other. This is when you see stereotypes presenting. Nurses not speaking up, allied health professionals (AHP) quiet and medical leading the participant debrief.” (UK, 34)
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ii.
“It's usually the nurses that do not speak up. There is the element of the hierarchical nature of society.
This is a very eastern thing that nurses do not speak up to doctors, when they know a doctor is making a mistake.” (Singapore, 74) |
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c. Embarrassment Fear of Judgement & confrontation avoidance |
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i.
“They don't want to expose weakness in knowledge.” (Denmark, 18)
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ii.
“Certain participants fear “losing face”. In situations when hierarchy is steep, the debriefer is less likely to confront a more senior e.g. a chief or an attending physician as relentlessly as he would participants of a lower hierarchy. This is because the debriefer doesn't dare confront him or her in front of the others. In other words, in situations with steep hierarchy attendings and chiefs are approached more gently than staff members of a lower hierarchy.” (Switzerland, 34)
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iii.
“I am uncomfortable talking about the specific clinical content because I am not a clinician.” (US, 40)
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iv.
“I spend a lot of time training faculty to debrief. I have noticed some cultures (Indian for example) have a very difficult time with advocacy inquiry. I've noticed individuals struggle in sharing their observations and judgements.” (US, 40)
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v.
“Sometimes I am not willing to correct wrong diagnoses of the case since now I don't want to embarrass the participants in front of their colleagues, which may lead to hate simulation. I feel this probably because we have just started program in our unit within a few years.” (Japan, 54)*
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d. Great Expectations “Doctors can do no wrong” |
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i.
“The historical structure, where physicians-especially consultants- are seen as experts per definition, makes an open approach to discussing more personal competencies difficult. When it is expected in the clinical routine that the physician is the most competent person in the room, and then it looks like that it is really risky for physicians specially to talk about weaknesses, etc.” (Denmark, 18)
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ii.
“It's not culturally insensitive, but lots of people, particularly the physicians have been brought up in a culture where recognition of skill or knowledge deficiency may have not been rewarded.” (US, 40)
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a. Debriefing Medical Content or CRM |
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| b. Language: Lost in Translation |
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i.
“The thing that always strikes me again and again when debriefing people from the French or Italian speaking part of Switzerland. We will be speaking in Swiss German or High German (aka German) to each other, but I know that their linguistic background is either francophone or italophone. They will frequently try to categorize things as being either correct/right or incorrect/wrong-- to me right or wrong is not the relevant issue. I perceive them as being very judgmental, but the judgmental part is precisely what I try to remove from the debriefing and rather focus on the frame behind the action. They have the tendency to judge themselves and other participants and say things like: “Yes, I see what I did wrong.” It is particularly difficult for me to get them to examine the frame behind an action rather than categorizing the action into right or wrong.” (Switzerland, 34)
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ii.
“Some of the foreign doctors have cultural/communication problems. Might not be able to express them because of lack of [local language] skills, lacking clinical expertise relevant to their level. Difficulty: if physician, whose med. Skills are not good enough, he might create frustration in the team and those cannot be solved just by talking about them. Especially when from the Middle East and cannot/won't admit to this. Might trigger so strong emotions that communication breaks down.” (Denmark, 18)
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a. Focus on error – free performance |
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i.
“This is mostly due to how the medical education system works, where up until this point in their training getting 100% on a test is considered success and getting 60% is failure. So, hearing about opportunities for improvement or failure or deficiency can be off-putting, considered to other things, particularly knowledge or skill.” (US, 40)
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ii.
“Not used to simulation, not expected, not much experience. People are afraid before simulation, then relieved afterwards.” (Slovenia, 71)
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iii.
“Culturally, often people do not understand advocacy/inquiry, as they are more used to being told what to do. That can be quite challenging.” (Singapore, 74)
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