Cultural considerations in debriefing: a systematic review of the literature

Abstract

Background

Conversations are influenced by cultural perceptions, beliefs and values. Debriefing is a learning conversation. Without cross-cultural engagement or culturally relevant teaching, learning may be compromised and may result in an outcome opposite of that intended.

Objective

This systematic review explores cultural considerations in healthcare simulation debriefing. We sought to explore findings that could help debriefers create culturally responsive and inclusive debriefings.

Study selection

Studies were included if they were peer-reviewed articles in any language and focused on healthcare simulation debriefing and global cultural considerations. Research study methods included qualitative, quantitative or both. The review included any health-related profession and level of learner.

Findings

Three studies met the criteria. The purposes of the three studies were significantly different and did not directly study cultural considerations in debriefing.

Conclusions

The learner–educator relationship is at risk and learning may be negatively impacted without addressing cultural awareness. More studies are needed to fully describe the effect of culture on successful debriefing.

Every educator likely has an experience where cultural differences present a barrier to an effective learning conversation. It is sometimes predictable but often not anticipated. While we have experienced cultural differences in ways where we recognise it when encountered, culture may influence conversations in ways that can be easily overlooked.¹ In learning conversations, recognised or unrecognised, cultural factors may transpose the intended learning outcomes.

As healthcare simulation-based education (SBE) gains recognition in academic and practice spheres as a powerful teaching and learning method,^{2 3} there has been adoption of its use across professions, practice levels, practice settings and geographical regions.^{4 5} Over time, simulationists and researchers have heightened the appreciation of the critical nature of debriefing in SBE,^6–9 often referred to as ‘the heart and soul of simulation’.¹⁰ SBE debriefings are focused conversations usually led by a facilitator (‘debriefer’) with learners (‘debriefees’) that typically occur directly following a simulation experience to reflect on aspects of the simulation, exploring and addressing the learner’s needs.^6–9

Feedback is essential for effective learning experiences. Debriefing dedicates time and attention for feedback, while expanding learning objectives through discussion. Debriefing facilitates major concepts of adult learning such as relevance, reflective practice, and goal-oriented and problem-centred learning using a common experience. Studies of debriefing support its importance and encourage practice and educator training in debriefing facilitation methods.7 8 11 12

Advances in debriefing support the use of conversational structure and communication techniques to effectively facilitate group and individual reflection. The art in debriefing is to generate an honest exploration of learners’ thoughts and meshing this exploration with feedback and teaching.^{7 13 14} Educators use various debriefing techniques, resulting in the creation of multiple methods that have been published over the last two decades. The vast majority of these methods have been found to be North American in both philosophical basis and practised techniques.¹⁵ These North American techniques have been adopted in other countries, with anecdotal evidence that the techniques, when applied to different cultures, might need adjustment for those particular cultures.^{16 17}

There are different types of cultures. Culture might be global, organisational, generational, professional, socioeconomic or religious. In this study, we refer to global culture, also known as national or ethnic culture. After considering multiple published and widely accepted definitions of global culture, we used the definition by Matsumoto¹⁸: ‘The set of attitudes, values, beliefs, and behaviors shared by a group of people, but different for each individual, communicated from one generation to the next’. By using the lens of Matsumoto’s¹⁸ definition we are able to better narrow our discussion of the elements of primary relevance in the papers that resulted from this review.

Culture is part of the conversational fabric of debriefing, shaping interactions and influencing how feedback is given and received. Because debriefing is a reflective process through collaborative conversation, culture inevitably affects debriefings. Cultural differences permeate the effectiveness of communication¹⁸ and how we teach and learn.¹⁹ Moreover, the risk of not acknowledging these cultural differences and the roles they play may present significant risk to the anticipated educational outcomes.^{17 19}

Purpose

This study endeavours to understand the degree of influence that cultural factors play in a debriefing, how culture influences debriefing, and which debriefing styles or techniques should be appropriately tailored to culture, if any.

Methods

A systematic review, using methodology promoted by the Joanna Briggs Institute (JBI), was conducted to synthesise the evidence on cultural considerations in debriefing contained in simulation literature.²⁰ The JBI methodology was chosen for its evaluation of validity and focus on congruity.²¹ Systematic reviews carefully select evidence-based studies to include in an appraisal or synthesis of evidence, providing stronger findings collectively. The Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines were followed in conducting this review.²⁰ The review team demographics are included in table 1. Four of the researchers (AC, KL, JCP, MC) conduct debriefings internationally, individually exploring applications in different cultures. One researcher (SD) has participated in debriefing sessions in culturally distinct locations. All researchers work with international learners.

Table 1.

Review team demographics

Reviewer	Gender/age	Profession	Self-reported ethnicity	Geographical location	Years of debriefing experience	Debriefing methods used	Geographical experience debriefings
AC	Male/30–40	Anaesthesiologist/educator	Chinese	Hong Kong	7 years	Debriefing with good judgement, Plus Delta	USA, Hong Kong, Singapore
MC	Male/40–50	Director/educator	Caucasian	New Hampshire, USA	17 years	PEARLS, Rapid Cycle, Plus Delta	USA, KZ, Antarctica
SD	Female/40–50	Professor/doctor	African American	Washington, DC	0 years, debriefee experience	Not applicable	USA, UK, Caribbean
KL	Female/50–60	Executive director/nurse	Caucasian	Doha, Qatar	17 years	Mixed, debriefing with good judgement, PEARLS	USA, Canada, Qatar, Caribbean, UAE, Saudi Arabia
JCP	Female/40–50	Professor/nurse practitioner	Asian-American	Boston, USA	19 years	Mixed, mainly debriefing with good judgement and Plus Delta	USA, AUS, Saudi Arabia, UAE, Chile, China, PR, Canada, Singapore, France, Italy

AUS, Australia; KZ, Kazakhstan; PEARLS, Promoting Excellence and Reflective Learning in Simulation; UAE, United Arab Emirates.

Search strategies

Three independent systematic searches of academic and grey literature databases were performed without limitation on publication date; the last search occurred in February 2021. Electronic searches of HOLLIS Harvard unified database that includes Ebscohost (CINAHL, PubMed, ERIC), ProQuest, PsycINFO, MEDLINE and Google Scholar were conducted and adapted in syntax across databases. The authors consulted with a librarian on the final search strategy (see online supplemental appendix I). Boolean connectors AND, OR and NOT were used to combine the following MeSH and search terms: cultur*, debriefing, simulation, simulation-based, health care, healthcare; and keywords: diversity, multicultural (see online supplemental appendix I). The list of search terms was developed through review of the healthcare debriefing literature. Additional hand searching was performed through reference lists, related journals and citations of articles in books. Additional searches were performed to screen publication lists for the five most frequent authors publishing under this topic. Additionally, a librarian ran searches monthly during our screening and analysis. Three authors (JCP, KL, AC) conducted the initial screenings of title, abstract and subsequent full-text manuscripts with at least two authors. All authors analysed the included manuscripts. Disagreements were identified using Covidence software application²² and reconciled through discussion and consensus. Selection was based on inclusion and exclusion criteria.

Inclusion criteria

Studies were included if they were peer-reviewed articles, published in any language and focused on healthcare simulation debriefing and global cultural considerations. Research study methods included qualitative, quantitative or both. The review included any health-related profession and level of learner. The date range was open.

Exclusion criteria

Articles were excluded if they were not peer-reviewed, the subjects of the studies were not health-related professionals or students, the aims did not explicitly focus on debriefing, or the focus did not include cultural considerations. Articles that were not primary sources, including but not limited to editorials or review articles, were not viewed as research studies and were thus excluded.

Search results

The initial search found 180 unique articles. After reviewing the titles and abstracts to fit inclusion and exclusion criteria, 28 articles were selected for full-text review, after which 25 were excluded (figure 1).

Figure 1.

PRISMA diagram of article data. PRISMA, Preferred Reporting Items for Systematic Review and Meta-Analysis.

Data extraction

The authors read the included articles and extracted data based on a standardised coding form including reference, aims, methods, search strategy, assessment of the quality of measures, findings, definition of resilience, interventions used in the studies, suggested factors of resilience (helpful or harmful), suggested educational considerations, measures of resilience used by studies and areas for future research. Data extraction included basic simulation elements and all elements of debriefing and feedback.²³ The authors independently reviewed extracted data and, using a constant comparative method, determined common themes and differences. The authors intended to assess the quality of measures using JBI Appraisal; however, due to the low amount of articles that met the inclusion criteria and the nature of their focus and measures (not directly related to studying cultural considerations), assessing rigour would be extraneous and would not support the focus of the study.

Results

Study characteristics and methodologies

Three studies met the specified inclusion and exclusion criteria.^24–26 Perry et al ²⁴ used a case study approach to identify the impact of culture on performance and team behaviours in neonatal resuscitation simulation and interactions between learners during debriefings in a low-resource setting in Honduras. Ulmer et al ²⁵ used a mixed-methods approach to study the impact of culture on interactions during debriefings through self-reported observations via structured interviews of experienced debriefers from 26 countries. Robinson et al ²⁶ used a pre/post assessment of debriefing to evaluate the effectiveness of a culturally contextualised simulation faculty development programme. A summary of the data extraction is presented in the online supplemental table.

Definition of culture and aspect of culture studied

All three studies focused on national cultures specifically (as per inclusion criteria) and followed Hofstede’s^{27 28} framework for analysis of national cultures. As a result, all three studies defined culture as a collective identity based on beliefs, behaviours, shared history and experiences of a group of people that subsequently influences their patterns of thinking.^24–26 Specifically, out of the six cultural dimensions described by Hofstede, power distance, collectivism, uncertainty avoidance, masculinity, long-term orientation and indulgence, all three studies evaluated the influence of power distance on debriefing. Power distance is the extent to which less powerful members of institutions and organisations within a country expect and accept that power is distributed unequally.²⁹ The dimension of power distance was further quantified into power distance index (PDI), which is the measure of the ‘acceptance of inequality in distribution of power in a certain society’.²⁹ Perry et al ²⁴ further considered how collectivism, masculinity and uncertainty avoidance may influence interactions during debriefing.

Cultural dimensions outcomes

Perry et al ²⁴ observed the amount of speaking by participants as a marker for the effect of power distance on debriefing interaction dynamics. Although they did not perform a qualitative analysis on the observations, they suggested from these observations that the high PDI context of Honduras resulted in nurses being quiet and less expressive during debriefing. Additionally, the authors attributed the quietness of nurses to dimensions of high collectivism (team members do not commonly challenge superiors), masculinity (women do not contribute as much during debriefing in a typical patriarchal society) and high uncertainty avoidance (where participants are new to medical simulation and uncertain about the educational modality).²⁴

Ulmer et al ²⁵ analysed the impact of power distance on perceived learner interactions during a debriefing by quantitatively correlating PDI with prespecified debriefing characteristics—these include talking time, interaction pattern, interaction style, and initiative for interactions for facilitator/participants and debriefing content and difficulty discussing non-technical skills. According to debriefers’ perceptions, high PDI cultures were correlated with more debriefer talking time, less interaction between participants, fewer open-ended questions by debriefers, fewer interactions initiated by participants, more focus of debriefings on technical/medical issues, and difficulty in addressing issues such as speaking up and admitting to personal uncertainty.²⁵

Robinson et al ²⁶ examined Observational Structured Assessment of Debriefing (OSAD) tool scores of facilitators who had participated in their 2-day facilitator training course prior to, after and at 12 months post-training. The methods of this study mention debriefing strategies being contextualised to the local setting, but specific details were not given in the adaptations used. Nor was it made clear what cultural context differences existed between course faculty, facilitators and learners that were ultimately debriefed. Through the OSAD tool, Robinson et al ²⁶ were able to demonstrate that international faculty can focus on allowing the learner to speak more, involve learners in more interactions, encourage learners to initiate more interactions and prioritise the learner agenda.

Limitations and bias

Researchers

While we had diversity in ethnic culture (see table 1), all researchers have used North American debriefing models and were trained or self-trained in debriefing methods by North American educators through courses and conference sessions.

Data

Non-English papers were included in the screening and reviewed, but did not meet the inclusion criteria. Majority of the researchers of the included studies are from North America; hence, the data may be laden with North American perspectives.

A major limitation was the poorly described methodology of the included articles, which compromised the credibility of the resulting conclusions. Furthermore, the researchers were unable to comparatively synthesise the findings of these studies as the differing aims, methodologies, levels of rigour and cultural outcomes studied made meaningful comparison difficult. There was potential bias in all three studies. In the study by Perry et al,²⁴ the authors did not perform qualitative assessment of the impact of culture on debriefings, and it was unclear how the observations led to the conclusion of the relationship between power distance and debriefing interactions. The reflexivity by the authors and debriefers was also unclear, to what extent their own lens and assumptions of another culture contributed to the interpretation of the behaviours of the learners. Also unclear was how the relationships between the facilitator and the learners affected the dynamics within the simulation debriefing. The study by Ulmer et al ²⁵ was limited to self-reporting of perceived debriefing interactions by debriefers. Therefore, the expressed views may not be representative of their actual debriefing practices. The cultural background of the debriefers, which in itself may affect their perception of the contribution of culture on debriefing, was also unclear. In both studies, the debriefing models were not specified, which may confound the establishment and maintenance of engaging learning environments within the respective contexts. The study by Robinson et al ²⁶ relied on a tool that was designed to evaluate Western debriefing methods and was itself designed in a Western context. Moreover, the methodology for contextualising the debriefings themselves was not adequately described. Both of these elements leave room for potential bias and misunderstanding.

Time and cultural models

All three studies used the Hofstede model. Hofstede’s²⁸ study of organisations in many countries led to an understanding that there were shared cultural aspects and socialisation skills among people from the same country that were not specific to all working for the same employer, prompting him to further study national culture and organisational culture. Hofstede’s framework examines various national and organisational cultures despite considerable criticism of the model.¹⁵

The use of this model may serve as a limitation and bias in the data. The passage of time and evolution of new generations influence cultural factors and considerations. For example, the landscape of cultural considerations will likely change shape in healthcare education and workforce as a result of events in the 2020 era of heightened attention to injustice, racism, diversity, equity, inclusivity and belonging.

Discussion

The three studies each used Hofstede’s guiding framework on dimensions of national cultures. In Hofstede’s original work, employee attitudes survey data were collected between 1967 and 1973 from IBM subsidiaries across 66 countries.²⁷ On analysis of these data and subsequent data, Hofstede discovered six dimensions of cultural attributes and developed surveys to quantify these attributes for comparison between nations. McSweeney³⁰ and Limaye and Victor³¹ suggest that this sample is unlikely to represent an entire national culture. In addition, they question whether a survey designed for a different purpose can provide adequate data to determine differences in national culture, as purported by Hofstede. Although this model has been criticised, it is the most dominant model used in cross-cultural research and was presumably chosen due to the breadth of data available for comparison. Arguably, the cultural dimensions used by the Global Leadership and Organizational Behavior Effectiveness research programme, which refined and expanded on Hofstede’s model for the reasons above, may have been better suited. The dimension of power distance is central to both of these cultural models and has been identified as a key component affecting the nature of discussion, which is relevant to debriefing.³² Ulmer et al ²⁵ concluded that high PDI was associated with an autocratic model of teaching and less learner engagement and expression. Interestingly, this characterisation of debriefing in high PDI settings informed the study by Robinson et al ²⁶ with the creation of a culturally contextualised curriculum for a low PDI setting. These studies presume a culturally homogenous group of faculty and learners, subscribing to one national culture and an inherent set of values and practices, which is rare in many healthcare centres.

According to the WHO³³ migration of healthcare workers to other countries within the Organisation for Economic Co-operation and Development group has risen 60% for doctors and nurses over the previous 10 years. Globalisation of the healthcare workforce, often from low-income to high-income countries,³⁴ results in organisational diversity, where the majority of the workforce may no longer represent the national identity. This is evident in Qatar, for example, where 99.2% of nurses and 93.6% of physicians are from outside the country.³⁵ To debrief as if only a Middle Eastern cultural perspective was present would be inappropriate. Moreover, Waterval et al ³⁶ discuss the increasing number of curriculum partnerships attempting to establish curricula originally designed for Western learners in non-Western contexts. In these cross-border curriculum relationships national diversity of learners and facilitators demonstrates a similar effect to globalisation of the workforce where the national identity of the facilitators, learners and anticipated practice environments may not be consistent with debriefing methodology. Perry et al ²⁴ demonstrate a different example of the discourse between culture and gender norms by concluding that while femininity is a predominant dimension for Honduras, the behaviours of subordination with less communication may demonstrate that workplace power structures over-ride that dimension. The effects of globalisation and culture change must be considered when interpreting data related to Hofstede’s 6D model.

Debriefing is a critical tool for the educator, facilitating learner reflection and actionable steps for improvement. In healthcare it has found wide application across all settings, providing psychological support after critical events in many care settings. Several models have been developed with strategies for successful debriefing, but these models do not consider the cultural context of the debriefing.¹⁵ Review of the relevant literature underscores the lack of recognition of cultural considerations in debriefing and leaves us with several questions: Should professional engagement be guided by dimensions of culture? Would a learner-centred approach to debriefing be more acceptable in a low PDI compared with a high PDI setting? How can cultural considerations be applied in a multicultural environment?

Of growing concern in health professions education is the potential for neocolonialism in the perpetuation of, particularly, Western-centric models of medical education.³⁷ Fundamentally, debriefing is meant to be a reflective process on the encounter that was just experienced. This process is just as susceptible to an underlying theme of imperialism as any other form of education.³⁷ In this sense, the relationship between home and host institutions needs to be actively examined with a particular focus on the cultural elements of the entirety of the simulation programme and educational offerings.^{26 36}

While some work has been done to consider cultural considerations in other elements of cross-border curriculum partnerships,³⁸ the specifics of cultural considerations in debriefing are not adequately described. All three studies identified the importance of cultural factors on debriefing but provided a limited view of what those effects might be, how they were observed, and whether or how they might or should be mitigated. The risks of not exploring these elements as they relate to debriefing are multifaceted. Of primary concern would be the capacity to explore the emotional response and decision-making process in which a learner engages. One’s cultural experience and background may significantly affect how a learner responds to a simulated experience.³⁹ Without a true understanding of the perspective of the learner and the potential biases of the facilitator, there is potential for misunderstandings and missed learning opportunities. Additionally, facilitators may limit or damage the essential trust relationship that must exist for high-quality debriefing. Without this relationship and an ability to foster it using established debriefing methodologies, education–practice gaps may persist despite the best efforts to train out of them.

Without an understanding of the application of cultural considerations in debriefing, the goal to meet the learner’s needs may be inadvertently transposed by meeting the debriefer’s needs or desires. In this sense, faculty development is key. Training in several areas would be of particular relevance for debriefing facilitators. Cultural intelligence, the ability of an outsider to interpret unfamiliar and ambiguous gestures the way an insider might, could be a boon in the interpretation of many inputs from learners throughout a debriefing.⁴⁰ Emotional intelligence, the ability to perceive and accurately interpret emotions in oneself and others, can assist in the interpretation of signals relating to interprofessional relationships and the ability to navigate sometimes emotionally charged interactions with significant cultural differences.⁴¹ Each of these plays a crucial role in achieving cultural competence and cultural humility through a self-reflection process where an individual learns about another’s culture and self-examines his/her own beliefs and cultural identities.^{42 43} These concepts of cultural humility and competence allow practice in the application of cultural intelligence knowledge and acquisition of culturally inclusive understanding and skills.⁴⁴

Conclusion

The three studies included in this review suggest that cultural factors play a role in debriefing; however, the degree of influence of these factors has not yet been adequately described. Debriefing in a culturally homogenous environment should be contextualised for a more learner-centred approach and validated cultural models may play a role in guiding adaptation of debriefing strategies. This contextualisation may be managed in many ways to allow for closing the gap between the cultural context in which the method was designed versus the context in which it is being used. Additionally, the multicultural setting offers its own unique challenges and quantifying the impact of culture in this setting would be an elusive goal. Instead, it may be more important to ensure that debriefing techniques and training are culturally appropriate and sensitive for a multicultural audience, and that participants are trained in cultural intelligence, cultural humility and cultural competence. The methods for adapting to a multicultural debriefing context may be similar or distinctly different from those in a homogenous context. More studies are needed to define culture in both homogenous and heterogenous settings and to better understand how adaptations might be made in debriefing model, facilitator skill and technique, and other educational pedagogy to better describe how to most effectively debrief in cross-border and multicultural contexts and partnerships towards equitable and non-oppressive learning environments.

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. The data are in a Massachusetts General Hospital/Harvard Medical School protected dropbox managed by the corresponding author (JCP).